Suicide
Conditions
Keywords
Family Caregivers, Spouse Caregivers, Veterans, Suicide, Clinical Trial, Military Families, Military Psychology
Brief summary
The management of suicide risk is a pressing national public health issue especially among Veterans, and there exist no guidelines of how best to involve family members in this effort. This proposal will integrate family and couples communication skills training with suicide safety planning. The goal is for the sharing of Veteran suicide safety plans with family members and the construction of a parallel family member safety plan, in efforts to mobilize and support family involvement.
Detailed description
Psychological models of suicidality emphasize the role of social factors in the development and intensification of suicidal thoughts and behavior, including feeling like a burden on family and friends, feelings of isolation and not belonging, and perceptions of diminished support from one's family and social network. Despite the critical role of family factors in protecting against suicidality, families lack education on how their behavior can help avert or unwittingly aggravate suicidal thoughts/ behavior. Families worry about their relative but feel uncertain of how to help and need professional guidance. Family worries about suicidality are associated with compromised family physical and mental health and consequently, diminished ability to offer needed support. Because suicide safety plans rely on mobilizing support in times of crisis, families need to be equipped to provide needed support. Family recommendations from the VA Behavioral Health Autopsy Program (BHAP) Annual Report 6/30/15 based on interviews with 114 family members highlighted the importance of: 1. educating families about suicide warning signs: 2. improving communication between the veteran and family member 3. involving the family in the veterans' treatment to enhance support and trust 4. providing families with coaching on how to assist their loved one to seek help. Management of suicidal behavior is covered in comprehensive family psychoeducation programs, but there is an urgent need for a brief family-based intervention specifically focused on suicide prevention that can be used in conjunction with the currently mandated SSP and as a part of routine care. Despite the enrichment of VA suicide prevention services and implementation of the national suicide hotline, Veteran suicide completions have risen to 22 per day and suicide attempts numbered over 15,000 in 2012. These data underscore the urgency of developing additional interventions targeting suicidal Veterans. One potential avenue to further suicide treatment and rehabilitation efforts is to develop strategies that maximize family support, however almost no family interventions exist for suicidal Veterans. The construction of a Suicide Safety Plan (SSP); a best practice, is mandated throughout the VA system, and a vital component of the VA's coordinated effort at suicide prevention and recovery. The pilot data on patterns of SSP use in suicidal Veterans highlighted the importance of sharing the plan with family or close friends. However, respondents also noted significant obstacles in their ability to reach out to others when in distress. To the knowledge of Investigators, there are currently no recommended guidelines or mechanisms for involving family in safety planning, despite its inclusion as a step of the plan. Safe Actions for Families to Encourage Recovery (SAFER) a novel suicide safety planning family intervention has been designed to fill this critical gap and provide a mechanism to communicate about safety planning. SAFER, a 4-session, family intervention, combines education about suicide and suicide safety planning with communication skills training from evidence-based practices. The aim is to facilitate communication about suicide safety planning and to develop both a Veteran and family member safety plan. Data from this project will test the intervention's feasibility, acceptability and preliminary efficacy in a Stage II small-scale randomized clinical trial in 39 moderate suicide risk Veterans and their supporting partners. The comparison condition will be safety planning without supporting partner involvement plus weekly check-in phone calls. Primary Veteran outcomes include reducing suicidal ideation/behavior. Secondary Veteran outcomes include reducing suicidal cognitions (hopelessness, perceived burdensomeness, thwarted belongingness) and depression and improving subjective social support. Supporting Partner primary outcomes include reducing caregiver burden and secondary outcomes of improving suicide-related coping and family empowerment.
Interventions
BEHAVIORALSafe Actions for Families to Encourage Recovery
A novel, 5-session intervention to enhance currently mandated VA suicide safety planning by involving family members to support its implementation. Incorporation of education about suicide risk factors and teaching communication skills of active listening and making a positive request will supply Veterans and family members with the knowledge and tools needed to 1) identify potential warning signs, and 2) discuss Veteran ideation or family concerns with assurance that such requests will be listened to with validation and support, creating an ally for the suicidal Veteran in his struggle. As discussed above, research has demonstrated compellingly that suicidal desire is motivated by two interpersonal factors; perceived burdensomeness and thwarted belongingness. SAFER aims to increase family support for the Veteran to directly mitigate Veteran loneliness and sense of being a burden to others.
BEHAVIORALIndividual Safety Planning Intervention
The comparison condition will be an assessment-only enhanced treatment-as-usual intervention called the Individual Safety Planning Intervention (I-SPI).
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Masking description
The individual who evaluates the outcomes of interest will not know the assigned condition of the participants.
Intervention model description
Participants are assigned to one of two groups in parallel for the duration of the study.
Eligibility
Sex/Gender
ALL
Age
18 Years to 89 Years
Healthy volunteers
No
Inclusion criteria
Inclusion criteria-Veterans: * Eligible Veterans must be identified as at moderate risk for suicide, defined as: * evidence of current (within the past week) suicidal ideation * plan or intent on the Columbia Suicide Severity Rating Scale (C-SSRS), but scoring less than or equal to 4 on the C-SSRS Behavior Scale, and without history of a lethal suicide attempt in the last 3 months. Inclusion criteria also include the availability of a consenting, qualifying family member or spouse/cohabiting partner. Inclusion criteria-family member/significant others: * Family members/friends must meet at least three (two for nonrelatives) of five criteria: * is a spouse, co-habiting significant other or parent * has more frequent contact than any other caregiver * helps to support the patient financially * is contacted by treatment staff for emergencies * has been involved in the patient's treatment
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Veteran Suicidal Ideation | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Suicidality will be measured using the Columbia Suicide Severity Rating Scale. The C-SSRS was used across time points to record level of ideation, lifetime suicide attempts, and recent suicide attempts. The follow-up version of C-SSRS measured suicidal ideation and behavior that had occurred since the last assessment. The scale has inter-rater reliability of .97 and has been used extensively in prospective suicide studies. The scale has a minimum value of 0 and a maximum value of 5. Higher scores mean a worse outcome (more severe ideation). |
| Supporting Partner Caregiver Burden | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Caregiver burden will be evaluated by the Caregiver Burden Inventory (CBI), a 24-item scale assessing caregiver burden in four areas: physical, social, emotional and time dependence burden. Investigators found a large effect size in the pilot multifamily group study on this scale (Cohen's d = 1.03). Items were averaged to create an overall measure of caregiver burden and showed excellent internal consistency in this study (α =.94). CBI scores range from 0 (minimum) to 4 (maximum). Higher scores mean a worse outcome (greater caregiver burden). |
| Number of Veterans With at Least 1 Suicide Attempt | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | These are the number of Veterans who reported at least one or more behaviors coded as actual suicide attempts since last visit using the Columbia Suicide Severity Rating Scale (C-SSRS). The follow-up version of C-SSRS measured suicidal ideation and behavior that had occurred since the last assessment. The scale has inter-rater reliability of .97 and has been used extensively in prospective suicide studies. A behavior was considered an actual suicide attempt if it was a potentially self-injurious act with any intent to die associated with it. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Veteran Perceived Burdensomeness | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Perceived burdensomeness will be evaluated by Interpersonal Needs Questionnaire (INQ-15). The INQ is has demonstrated excellent internal consistency for Perceived Burdensomeness (PB) (α= .95). Scores on each subscale were averaged so that higher scores represent a greater degree of their respective constructs. Perceived burdensomeness scores range from 1 (minimum) to 6 (maximum). Higher scores mean a worse outcome (greater perceived burdensomeness). |
| Veteran Hopelessness | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Veteran hopelessness will be evaluated by the Beck Hopelessness Scale (BHS), a 20-item self-report measure with adequate reliability and validity which has been predictive of suicide in psychiatric inpatients. The BHS measures three aspects of hopelessness: feelings about the future, loss of motivation, and expectations. Items are true-false and are summed to get a total BHS score, ranging from 0 to 20. Higher scores reflect a worse outcome (greater hopelessness). |
| Veteran Depression | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Veteran depression will be evaluated by the widely-used Beck Depression Inventory-II (BDI-II) (Cronbach's = .92). The BDI-II contains 21 items assessing depressive symptoms, each with minimum scores of 0 and maximum scores of 3. Item scores were summed, leading to a total score range of 0-63. Higher scores mean a worse outcome (more severe depressive symptoms). |
| Veteran Suicide Related Coping | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Suicide-related coping will be evaluated by the Stanley Suicide-related Coping Scale (SRCS), a 21-item self-report measure developed by Stanley, Green, Holloway, Brenner & Brown to evaluate appraisal of one's ability to cope with suicidal ideation and urges, as well as ability to use the Safety Plan. Examples of items are: I am at the mercy of my suicidal thoughts, I have several things I can do to get through a suicidal crisis. Scores were averaged so that higher scores represent greater confidence and breadth of approaches to coping with suicidal thoughts and feelings (better outcome). SRCS scores have a minimum of 0 and a maximum of 4. |
| Veteran's Report of Family Problem Solving | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Veterans' reports of family problem solving will be evaluated by the 5-item Problem Solving subscale of the Family Assessment Device (FAD). Subscales have acceptable internal consistency (α = .72 to .83). Each item has a minimum score of 1 and a maximum score of 4, and were averaged to create a total score range of 1-4. Higher scores reflect worse outcomes (lower problem solving ability). |
| Veteran's Report of Family Communication | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Veterans' reports of family communication will be evaluated by the 6-item Communication subscale of the Family Assessment Device (FAD). Subscales have acceptable internal consistency (α = .72 to .83). Each item has a minimum score of 1 and a maximum score of 4, and were averaged to create a total score range of 1-4. Higher scores reflect worse outcomes (worse communication). |
| Caregiver's Empowerment to Help Veteran | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Caregiving self-efficacy/empowerment will be evaluated using the 12-item family subscale from the Family Empowerment Scale. This scale assesses the family's knowledge of mental health services and perceived ability to manage crises, and has demonstrated sensitivity to change in family intervention studies. Each item has a minimum score of 1 and a maximum score of 5, and were averaged to create a total score range of 1-5. Higher scores mean a better outcome (greater empowerment). |
| Veteran Thwarted Belongingness | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | Thwarted belongingness will be evaluated by Interpersonal Needs Questionnaire (INQ-15). The INQ is has demonstrated acceptable internal consistency for thwarted belongingness in this sample (TB) (α =.79). Scores on each subscale were averaged so that higher scores represent a greater degree of their respective constructs. Thwarted belongingness scores range from 1 (minimum) to 6 (maximum). Higher scores mean a worse outcome (decreased feelings of belongingness). |
| Partner Support of Suicide-Related Coping | POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline) | We have developed a family counterpart to the Stanley Suicide-related Coping Scale for Veterans that taps family members' appraisal of their ability to participate effectively in Veteran safety planning. Items include, I recognize the triggers and warning signs for suicidal ideation/urges for my Veteran and I know the numbers for the mobile crisis team to contact and nearest hospital or urgent care facility to accompany my Veteran to in a crisis. This measure will be validated against the more general Family Empowerment Scale. Items were rated on a 0 (Strongly Disagree) to 4 (Strongly Agree) scale and were averaged with higher scores indicating greater self-efficacy when supporting the Veteran through suicidal crises (better outcome). Partner SRCS scores range from 0 (minimum) to 4 (maximum). |
Countries
United States
Participant flow
Recruitment details
The study recruited, consented, and randomized 39 Veterans at risk for suicide and 39 corresponding supporting partners over a 30-month period from a large VA medical center in a major metropolitan area in the North East. Recruitment sources included VA suicide prevention coordinators, a Veteran's primary clinician from the VA Medical Center's (VAMC) psychiatric inpatient unit or outpatient care center, or through community outreach (e.g., Vet Centers and higher education institutions).
Participants by arm
| Arm | Count |
|---|---|
| SAFER SAFER: A novel, 4-session intervention to enhance currently mandated VA suicide safety planning by involving family members to support its implementation. Incorporation of education about suicide risk factors and teaching communication skills of active listening and making a positive request will supply Veterans and family members with the knowledge and tools needed to 1) identify potential warning signs, and 2) discuss Veteran ideation or family concerns with assurance that such requests will be listened to with validation and support, creating an ally for the suicidal Veteran in his struggle. As discussed above, research has demonstrated compellingly that suicidal desire is motivated by two interpersonal factors; perceived burdensomeness and thwarted belongingness. SAFER aims to increase family support for the Veteran to directly mitigate Veteran loneliness and sense of being a burden to others.
Safe Actions for Families to Encourage Recovery: A novel, 4-session intervention to enhance currently mandated VA suicide safety planning by involving family members to support its implementation. | 38 |
| I-SPI The comparison condition will be an assessment-only enhanced treatment-as-usual (E-TAU), the currently mandated Individual Safety Planning Intervention (I-SPI). I-SPI incorporates weekly scripted check-in phone calls to review mood symptoms and use of the safety plan, which will then be given as feedback to the Veteran's primary mental health provider.
Treatment-as-Usual: The comparison condition will be an assessment-only enhanced treatment-as-usual called the Individual Safety Planning Intervention (I-SPI). | 40 |
| Total | 78 |
Baseline characteristics
| Characteristic | SAFER | Total | I-SPI |
|---|---|---|---|
| Age, Categorical <=18 years | 1 Participants | 1 Participants | 0 Participants |
| Age, Categorical >=65 years | 3 Participants | 4 Participants | 1 Participants |
| Age, Categorical Between 18 and 65 years | 18 Participants | 35 Participants | 17 Participants |
| Age, Continuous | 48.68 years STANDARD_DEVIATION 16.24 | 45.62 years STANDARD_DEVIATION 14.52 | 51.90 years STANDARD_DEVIATION 15.62 |
| Caregiver's Empowerment to Help Veteran | 3.79 units on a scale STANDARD_DEVIATION 0.64 | 3.77 units on a scale STANDARD_DEVIATION 0.72 | 3.75 units on a scale STANDARD_DEVIATION 0.8 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 6 Participants | 14 Participants | 8 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 14 Participants | 25 Participants | 11 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Number of Veterans with at least 1 Suicide Attempt | 10 Participants | 19 Participants | 9 Participants |
| Partner Support of Suicide-Related Coping | 3.23 units on a scale STANDARD_DEVIATION 0.81 | 3.3 units on a scale STANDARD_DEVIATION 0.84 | 3.37 units on a scale STANDARD_DEVIATION 0.87 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 2 Participants | 1 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 8 Participants | 20 Participants | 10 Participants |
| Race (NIH/OMB) More than one race | 2 Participants | 5 Participants | 4 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 4 Participants | 7 Participants | 3 Participants |
| Race (NIH/OMB) White | 5 Participants | 7 Participants | 2 Participants |
| Region of Enrollment United States | 19 Participants | 39 Participants | 20 Participants |
| Sex: Female, Male Female | 2 Participants | 25 Participants | 12 Participants |
| Sex: Female, Male Male | 6 Participants | 14 Participants | 16 Participants |
| Supporting Partner Caregiver Burden | 1.39 units on a scale STANDARD_DEVIATION 0.92 | 1.23 units on a scale STANDARD_DEVIATION 0.94 | 1.06 units on a scale STANDARD_DEVIATION 0.96 |
| Veteran Depression | 24.36 units on a scale STANDARD_DEVIATION 11.75 | 28.43 units on a scale STANDARD_DEVIATION 13.66 | 32.5 units on a scale STANDARD_DEVIATION 15.56 |
| Veteran Hopelessness | 6.95 units on a scale STANDARD_DEVIATION 5.79 | 9.34 units on a scale STANDARD_DEVIATION 6.18 | 11.72 units on a scale STANDARD_DEVIATION 6.57 |
| Veteran Perceived Burdensomeness | 2.84 units on a scale STANDARD_DEVIATION 1.56 | 2.94 units on a scale STANDARD_DEVIATION 1.59 | 3.03 units on a scale STANDARD_DEVIATION 1.61 |
| Veteran's Report of Family Problem Solving | 2.27 units on a scale STANDARD_DEVIATION 0.62 | 2.36 units on a scale STANDARD_DEVIATION 0.68 | 2.44 units on a scale STANDARD_DEVIATION 0.74 |
| Veteran's Reports of Family Communication | 2.42 units on a scale STANDARD_DEVIATION 0.37 | 2.48 units on a scale STANDARD_DEVIATION 0.39 | 2.53 units on a scale STANDARD_DEVIATION 0.41 |
| Veteran Suicidal Ideation | 3.26 units on a scale STANDARD_DEVIATION 1.69 | 3.51 units on a scale STANDARD_DEVIATION 1.51 | 3.75 units on a scale STANDARD_DEVIATION 1.33 |
| Veteran Suicide-Related Coping | 3.03 units on a scale STANDARD_DEVIATION 0.71 | 2.97 units on a scale STANDARD_DEVIATION 0.68 | 2.91 units on a scale STANDARD_DEVIATION 0.65 |
| Veteran Thwarted Belongingness | 3.23 units on a scale STANDARD_DEVIATION 1.02 | 3.43 units on a scale STANDARD_DEVIATION 0.96 | 3.62 units on a scale STANDARD_DEVIATION 0.9 |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 19 | 1 / 20 | 0 / 19 | 1 / 20 |
| other Total, other adverse events | 1 / 19 | 1 / 20 | 0 / 19 | 0 / 20 |
| serious Total, serious adverse events | 1 / 19 | 2 / 20 | 0 / 19 | 0 / 20 |
Outcome results
Primary
Number of Veterans With at Least 1 Suicide Attempt
These are the number of Veterans who reported at least one or more behaviors coded as actual suicide attempts since last visit using the Columbia Suicide Severity Rating Scale (C-SSRS). The follow-up version of C-SSRS measured suicidal ideation and behavior that had occurred since the last assessment. The scale has inter-rater reliability of .97 and has been used extensively in prospective suicide studies. A behavior was considered an actual suicide attempt if it was a potentially self-injurious act with any intent to die associated with it.
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Veterans in SAFER | Number of Veterans With at Least 1 Suicide Attempt | Post-Treatment | 0 Participants |
| Veterans in SAFER | Number of Veterans With at Least 1 Suicide Attempt | Extended Follow-Up | 0 Participants |
| Veterans in I-SPI | Number of Veterans With at Least 1 Suicide Attempt | Post-Treatment | 2 Participants |
| Veterans in I-SPI | Number of Veterans With at Least 1 Suicide Attempt | Extended Follow-Up | 1 Participants |
p-value: 0.49Fisher Exact
Primary
Supporting Partner Caregiver Burden
Caregiver burden will be evaluated by the Caregiver Burden Inventory (CBI), a 24-item scale assessing caregiver burden in four areas: physical, social, emotional and time dependence burden. Investigators found a large effect size in the pilot multifamily group study on this scale (Cohen's d = 1.03). Items were averaged to create an overall measure of caregiver burden and showed excellent internal consistency in this study (α =.94). CBI scores range from 0 (minimum) to 4 (maximum). Higher scores mean a worse outcome (greater caregiver burden).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to supporting partners (does not include Veterans) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Supporting Partner Caregiver Burden | Post-Treatment | 1.23 units on a scale | Standard Deviation 0.85 |
| Veterans in SAFER | Supporting Partner Caregiver Burden | Extended Follow-Up | 0.90 units on a scale | Standard Deviation 0.59 |
| Veterans in I-SPI | Supporting Partner Caregiver Burden | Post-Treatment | 1.00 units on a scale | Standard Deviation 0.86 |
| Veterans in I-SPI | Supporting Partner Caregiver Burden | Extended Follow-Up | 0.72 units on a scale | Standard Deviation 0.67 |
p-value: 0.69Hierarchical Linear Modeling/MLM
Primary
Veteran Suicidal Ideation
Suicidality will be measured using the Columbia Suicide Severity Rating Scale. The C-SSRS was used across time points to record level of ideation, lifetime suicide attempts, and recent suicide attempts. The follow-up version of C-SSRS measured suicidal ideation and behavior that had occurred since the last assessment. The scale has inter-rater reliability of .97 and has been used extensively in prospective suicide studies. The scale has a minimum value of 0 and a maximum value of 5. Higher scores mean a worse outcome (more severe ideation).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3 month follow up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran Suicidal Ideation | Post-Treatment | 1.50 units on a scale | Standard Deviation 1.93 |
| Veterans in SAFER | Veteran Suicidal Ideation | Extended Follow-Up | 1.00 units on a scale | Standard Deviation 1.31 |
| Veterans in I-SPI | Veteran Suicidal Ideation | Post-Treatment | 3.50 units on a scale | Standard Deviation 1.43 |
| Veterans in I-SPI | Veteran Suicidal Ideation | Extended Follow-Up | 3.38 units on a scale | Standard Deviation 2.13 |
p-value: 0.03Hierarchical Linear Modeling/MLM
Secondary
Caregiver's Empowerment to Help Veteran
Caregiving self-efficacy/empowerment will be evaluated using the 12-item family subscale from the Family Empowerment Scale. This scale assesses the family's knowledge of mental health services and perceived ability to manage crises, and has demonstrated sensitivity to change in family intervention studies. Each item has a minimum score of 1 and a maximum score of 5, and were averaged to create a total score range of 1-5. Higher scores mean a better outcome (greater empowerment).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to supporting partners (does not include Veterans) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Caregiver's Empowerment to Help Veteran | Post-Treatment | 3.71 units on a scale | Standard Deviation 0.78 |
| Veterans in SAFER | Caregiver's Empowerment to Help Veteran | Extended Follow-Up | 3.91 units on a scale | Standard Deviation 0.67 |
| Veterans in I-SPI | Caregiver's Empowerment to Help Veteran | Post-Treatment | 3.91 units on a scale | Standard Deviation 0.94 |
| Veterans in I-SPI | Caregiver's Empowerment to Help Veteran | Extended Follow-Up | 3.87 units on a scale | Standard Deviation 0.86 |
p-value: 0.64Hierarchical Linear Modeling/MLM
Secondary
Partner Support of Suicide-Related Coping
We have developed a family counterpart to the Stanley Suicide-related Coping Scale for Veterans that taps family members' appraisal of their ability to participate effectively in Veteran safety planning. Items include, I recognize the triggers and warning signs for suicidal ideation/urges for my Veteran and I know the numbers for the mobile crisis team to contact and nearest hospital or urgent care facility to accompany my Veteran to in a crisis. This measure will be validated against the more general Family Empowerment Scale. Items were rated on a 0 (Strongly Disagree) to 4 (Strongly Agree) scale and were averaged with higher scores indicating greater self-efficacy when supporting the Veteran through suicidal crises (better outcome). Partner SRCS scores range from 0 (minimum) to 4 (maximum).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to supporting partners (does not include Veterans) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Partner Support of Suicide-Related Coping | Post-Treatment | 3.65 units on a scale | Standard Deviation 0.46 |
| Veterans in SAFER | Partner Support of Suicide-Related Coping | Extended Follow-Up | 3.70 units on a scale | Standard Deviation 0.57 |
| Veterans in I-SPI | Partner Support of Suicide-Related Coping | Post-Treatment | 3.36 units on a scale | Standard Deviation 0.71 |
| Veterans in I-SPI | Partner Support of Suicide-Related Coping | Extended Follow-Up | 2.89 units on a scale | Standard Deviation 1.4 |
p-value: 0.03Hierarchical Linear Modeling/MLM
Secondary
Veteran Depression
Veteran depression will be evaluated by the widely-used Beck Depression Inventory-II (BDI-II) (Cronbach's = .92). The BDI-II contains 21 items assessing depressive symptoms, each with minimum scores of 0 and maximum scores of 3. Item scores were summed, leading to a total score range of 0-63. Higher scores mean a worse outcome (more severe depressive symptoms).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran Depression | Post-Treatment | 21.20 units on a scale | Standard Deviation 16.92 |
| Veterans in SAFER | Veteran Depression | Extended Follow-Up | 18.33 units on a scale | Standard Deviation 16.2 |
| Veterans in I-SPI | Veteran Depression | Post-Treatment | 29.07 units on a scale | Standard Deviation 18.67 |
| Veterans in I-SPI | Veteran Depression | Extended Follow-Up | 31.08 units on a scale | Standard Deviation 17.67 |
p-value: 0.55Hierarchical Linear Modeling/MLM
Secondary
Veteran Hopelessness
Veteran hopelessness will be evaluated by the Beck Hopelessness Scale (BHS), a 20-item self-report measure with adequate reliability and validity which has been predictive of suicide in psychiatric inpatients. The BHS measures three aspects of hopelessness: feelings about the future, loss of motivation, and expectations. Items are true-false and are summed to get a total BHS score, ranging from 0 to 20. Higher scores reflect a worse outcome (greater hopelessness).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3 month follow up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran Hopelessness | Post-Treatment | 7.40 units on a scale | Standard Deviation 6.49 |
| Veterans in SAFER | Veteran Hopelessness | Extended Follow-Up | 9.09 units on a scale | Standard Deviation 7.84 |
| Veterans in I-SPI | Veteran Hopelessness | Post-Treatment | 11.73 units on a scale | Standard Deviation 7.06 |
| Veterans in I-SPI | Veteran Hopelessness | Extended Follow-Up | 12.61 units on a scale | Standard Deviation 6.7 |
p-value: 0.81Hierarchical Linear Modeling/MLM
Secondary
Veteran Perceived Burdensomeness
Perceived burdensomeness will be evaluated by Interpersonal Needs Questionnaire (INQ-15). The INQ is has demonstrated excellent internal consistency for Perceived Burdensomeness (PB) (α= .95). Scores on each subscale were averaged so that higher scores represent a greater degree of their respective constructs. Perceived burdensomeness scores range from 1 (minimum) to 6 (maximum). Higher scores mean a worse outcome (greater perceived burdensomeness).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran Perceived Burdensomeness | Post-Treatment | 2.23 units on a scale | Standard Deviation 1.39 |
| Veterans in SAFER | Veteran Perceived Burdensomeness | Extended Follow-Up | 2.10 units on a scale | Standard Deviation 1.63 |
| Veterans in I-SPI | Veteran Perceived Burdensomeness | Post-Treatment | 2.60 units on a scale | Standard Deviation 1.68 |
| Veterans in I-SPI | Veteran Perceived Burdensomeness | Extended Follow-Up | 2.86 units on a scale | Standard Deviation 1.42 |
p-value: 0.16Hierarchical Linear Modeling/MLM
Secondary
Veteran's Report of Family Communication
Veterans' reports of family communication will be evaluated by the 6-item Communication subscale of the Family Assessment Device (FAD). Subscales have acceptable internal consistency (α = .72 to .83). Each item has a minimum score of 1 and a maximum score of 4, and were averaged to create a total score range of 1-4. Higher scores reflect worse outcomes (worse communication).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran's Report of Family Communication | Post-Treatment | 2.34 units on a scale | Standard Deviation 0.39 |
| Veterans in SAFER | Veteran's Report of Family Communication | Extended Follow-Up | 2.33 units on a scale | Standard Deviation 0.28 |
| Veterans in I-SPI | Veteran's Report of Family Communication | Post-Treatment | 2.33 units on a scale | Standard Deviation 0.54 |
| Veterans in I-SPI | Veteran's Report of Family Communication | Extended Follow-Up | 2.27 units on a scale | Standard Deviation 0.44 |
p-value: 0.16Hierarchical Linear Modeling/MLM
Secondary
Veteran's Report of Family Problem Solving
Veterans' reports of family problem solving will be evaluated by the 5-item Problem Solving subscale of the Family Assessment Device (FAD). Subscales have acceptable internal consistency (α = .72 to .83). Each item has a minimum score of 1 and a maximum score of 4, and were averaged to create a total score range of 1-4. Higher scores reflect worse outcomes (lower problem solving ability).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran's Report of Family Problem Solving | Post-Treatment | 2.33 units on a scale | Standard Deviation 0.86 |
| Veterans in SAFER | Veteran's Report of Family Problem Solving | Extended Follow-Up | 2.36 units on a scale | Standard Deviation 0.64 |
| Veterans in I-SPI | Veteran's Report of Family Problem Solving | Post-Treatment | 2.23 units on a scale | Standard Deviation 0.81 |
| Veterans in I-SPI | Veteran's Report of Family Problem Solving | Extended Follow-Up | 2.40 units on a scale | Standard Deviation 1.01 |
p-value: 0.62Hierarchical Linear Modeling/MLM
Secondary
Veteran Suicide Related Coping
Suicide-related coping will be evaluated by the Stanley Suicide-related Coping Scale (SRCS), a 21-item self-report measure developed by Stanley, Green, Holloway, Brenner & Brown to evaluate appraisal of one's ability to cope with suicidal ideation and urges, as well as ability to use the Safety Plan. Examples of items are: I am at the mercy of my suicidal thoughts, I have several things I can do to get through a suicidal crisis. Scores were averaged so that higher scores represent greater confidence and breadth of approaches to coping with suicidal thoughts and feelings (better outcome). SRCS scores have a minimum of 0 and a maximum of 4.
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran Suicide Related Coping | Post-Treatment | 3.15 units on a scale | Standard Deviation 0.71 |
| Veterans in SAFER | Veteran Suicide Related Coping | Extended Follow-Up | 3.12 units on a scale | Standard Deviation 0.59 |
| Veterans in I-SPI | Veteran Suicide Related Coping | Post-Treatment | 2.69 units on a scale | Standard Deviation 1.02 |
| Veterans in I-SPI | Veteran Suicide Related Coping | Extended Follow-Up | 2.70 units on a scale | Standard Deviation 0.86 |
p-value: 0.03Hierarchical Linear Modeling/MLM
Secondary
Veteran Thwarted Belongingness
Thwarted belongingness will be evaluated by Interpersonal Needs Questionnaire (INQ-15). The INQ is has demonstrated acceptable internal consistency for thwarted belongingness in this sample (TB) (α =.79). Scores on each subscale were averaged so that higher scores represent a greater degree of their respective constructs. Thwarted belongingness scores range from 1 (minimum) to 6 (maximum). Higher scores mean a worse outcome (decreased feelings of belongingness).
Time frame: POST TREATMENT ASSESSMENT- After completing intervention (Range 0.30-7.47 months; Mean=2.84 months from baseline); EXTENDED FOLLOWUP- 3-months after providing follow-up up to 1 year from enrollment (Range 3.10-11.43 months; Mean=6.32 months from baseline)
Population: Some participants lost between baseline and post-treatment follow-up and extended 3-month follow-up. These groups specifically refer to Veterans (does not include supporting partners) and therefore include about half of the total participants in the study.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Veterans in SAFER | Veteran Thwarted Belongingness | Post-Treatment | 2.85 units on a scale | Standard Deviation 1.27 |
| Veterans in SAFER | Veteran Thwarted Belongingness | Extended Follow-Up | 3.30 units on a scale | Standard Deviation 1.46 |
| Veterans in I-SPI | Veteran Thwarted Belongingness | Post-Treatment | 3.57 units on a scale | Standard Deviation 1.22 |
| Veterans in I-SPI | Veteran Thwarted Belongingness | Extended Follow-Up | 3.45 units on a scale | Standard Deviation 0.95 |
p-value: 0.87Hierarchical Linear Modeling/MLM