Amanda H. Kerbrat

Suicide Attempt Characteristics Among Veterans and Active-Duty Service Members Receiving Mental Health Services: A Pooled Data Analysis.

Past suicidal behaviors are among the strongest and most consistent predictors of eventual suicide and may be particularly salient in military suicide. The current study compared characteristics of suicide attempts in veterans (N = 746) and active-duty service members (N = 1,013) receiving treatment for acute suicide risk. Baseline data from six randomized controlled trials were pooled and analyzed using robust regression. Service members had greater odds of having attempted suicide relative to veterans, though there were no differences in number of attempts made. Service members also had higher rates of premilitary suicide attempts and nonsuicidal self-injury (NSSI). Veterans disproportionately attempted suicide by means of overdose. In veterans, combat deployment was associated with lower odds of lifetime suicide attempt, while history of NSSI was associated with greater attempt odds. Neither was significantly associated with lifetime suicide attempt in service members. Implications for suicide assessment and treatment are discussed.

Self-reported Usual Care for Self-directed Violence During the 6 Months Before Emergency Department Admission.

Background:The literature describing the health services individuals receive before and following self-directed violence (SDV) is limited. Objectives:This study examines services received for the 6 months preceding admission to an urban county medical center emergency department (ED) for SDV. We predicted that individuals with at least 1 prior act of SDV in the past 6 months would have received more services than those for whom the index admission was their only recent act. Methods:Participants were recruited from ED admissions during shifts selected to maximize representativeness. Participants (n=202) were interviewed using the Suicide Attempt Self-Injury Interview, Suicide Attempt Self-Injury Count, Treatment History Interview, Mini International Neuropsychiatric Interview, Brief Symptom Index, and SF-12. Results:The majority of index acts of SDV (79%) were suicide attempts. The participants were characterized by low socioeconomic status, substantial symptomatology, low physical and mental health functioning, and multiple psychiatric diagnoses. In the preceding 6 months, 34% were admitted to a hospital and 56% received crisis services (including 44% in the ED). Although three quarters (76%) had seen an outpatient medical provider and most (70%) received psychotropic medications, less than half of the sample received psychiatric services (40%) or outpatient psychosocial treatment (48%). As predicted, utilization for most types of usual care was higher for those engaging in SDV in the 6 months preceding the index admission. Conclusion:Individuals admitted to this ED for SDV received inadequate outpatient psychosocial and psychiatric services despite severe illness and disability.

A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual With Suicidal Soldiers

Objective: This study describes a randomized controlled trial called “Operation Worth Living” (OWL) which compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced care as usual (E-CAU). We hypothesized that CAMS would be more effective than E-CAU for reducing suicidal ideation (SI) and suicide attempts (SA), along with secondary behavioral health and health care utilization markers for U.S. Army Soldier outpatients with significant SI (i.e., > 13 on Beck’s Scale for Suicide Ideation). Method: Study participants were 148 Soldiers who presented to a military outpatient behavioral health clinic. There were 73 Soldiers in the experimental arm of the trial who received adherent CAMS; 75 Soldiers received E-CAU. Nine a-priori treatment outcomes (SI, past year SA, suicide-related emergency department (ED) admits, behavioral health-related ED admits, suicide-related inpatient psychiatric unit (IPU) days, behavioral health-related IPU days, mental health, psychiatric distress, resiliency) were measured through assessments at Baseline and at 1, 3, 6, and 12 months post-Baseline (with a 78% retention of intent-to-treat participants at 12 months). Results: Soldiers in both arms of the trial responded to study treatments in terms of all primary and secondary outcomes (effect sizes ranged from 0.63 to 12.04). CAMS participants were significantly less likely to have any suicidal thoughts by 3 months in comparison to those in E-CAU (Cohen’s d = 0.93, p=.028). Conclusions: Soldiers receiving CAMS and E-CAU significantly improved post-treatment. Those who received CAMS were less likely to report SI at 3 months; further group differences were not otherwise seen.

Examining the Impact of Suicide Attempt Function and Perceived Effectiveness in Predicting Reattempt for Emergency Medicine Patients

While previous studies have examined motivational aspects of self-directed violence, few studies have included specific motivations in predictive models for future suicide attempts. The current study utilized a sample of 160 individuals treated in an acute emergency setting following a suicide attempt who completed an interview battery that included an assessment of functional aspects of the index suicide attempt. A follow-up interview was conducted at 6 months to ascertain subsequent suicide attempts. The functional domains of suicide attempts were labeled as reduction-of-distress, communication, perceived better alternative to living, and self-loathing. Above and beyond other known risk factors, including history and highest lethality of previous self-injury, suicide attempts that served a communication function (OR = 0.18, p = .02, CI = 0.04, 0.73) and higher ratings of clinical dysfunction (OR = 3.41, p = .05, CI = 1.02, 11.36) were associated with a significant reduction in likelihood to engage in a suicide attempt during the 6-month follow-up window. Including the perceived effectiveness of the index suicide attempt in getting ones needs met strengthened the overall model predicting a suicide attempt in the follow-up window and was an independent risk factor above and beyond other variables in the model OR = 1.75, p = .04, CI = 1.02, 3.01). Assessment of functional aspects of suicide attempt is feasible and may improve formulation of risk in a population where typical risk factors for suicide are ubiquitous.

Gender Differences in Acquired Capability Among Active-Duty Service Members at High Risk for Suicide

The interpersonal-psychological theory of suicide (IPTS) differentiates the desire to die from the capability to inflict lethal self-injury. Despite increasing agreement in the literature regarding the theoretical relevance of the construct in understanding military suicide, acquired capability has rarely been evaluated among currently or recently suicidal active-duty service members. To this end, the present study pooled baseline data for 733 active-duty service members enrolled in one of two clinical trials to prevent suicide. We hypothesized that self-reported acquired capability would be higher among men, and would increase with (a) suicide attempt frequency and (b) combat deployment frequency. Lifetime history of suicide attempts was assessed using the Suicide Attempt Self-Injury Count. Scores of self-reported acquired capability were based on the 20-item version of the Acquired Capability for Suicide Scale (ACSS) and the 7-item fearlessness about death subscale (ACSS-FAD). Consistent with the IPTS, male gender, suicide attempts (none, single, multiple), and deployments (0, 1, 2, 3+) to a combat zone predicted increased ACSS and ACSS-FAD scores. Findings support the relevance of the IPTS in a military context.

Examining challenging behaviors of clients with borderline personality disorder

Few studies have examined effects of challenging behaviors of clients with borderline personality disorder (BPD) on psychotherapy outcomes. Dialectical behavior therapy (DBT) is an evidence-based treatment designed to treat chronic suicidality, self-directed violence (SDV), and emotion dysregulation, while targeting challenging behaviors. DBT has been shown to be effective with clients with BPD. We evaluated whether therapist reported challenging behaviors, such as high volume phone contacts or violating the therapists limits, during DBT would be associated with dropping out of DBT, severity and frequency of SDV, emotion regulation deficits, psychological symptom severity and clients and therapists satisfaction of treatment. The current study examined challenging behaviors reported by therapists in a sample of 63 psychiatrically disabled outpatient DBT clients diagnosed with BPD (73% women, average age 37 years). More frequent phone contacts were associated with a decrease in dropout and psychological symptoms, and an increase in client and therapist satisfaction. More avoidance/disengagement behavior was associated with more than twice the risk of SDV and a decrease in therapist satisfaction. Findings suggest that the phone coaching might serve to maximize client satisfaction and reduce the likelihood of dropout.

Validation of the Co-occurring Disorder Quadrant Model

Abstract The co-occurring disorders quadrant model has been used as a framework for characterizing the heterogeneity in persons with low- and high-severity substance use and psychiatric disorders. This study investigated the validity and stability of the quadrant model in 155 adults who presented to one county hospital with psychiatric, substance use, or medical complaints. Quadrant placement was defined using data that is routinely gathered in clinical care or available in administrative data sets (i.e., substance dependence diagnosis, Global Assessment of Functioning scores). Fifty-four percent (n = 84) of study participants were categorized into quadrant IV (high-severity psychiatric/substance use), followed by quadrant I (low-severity psychiatric/substance use) (n = 32, 21%), quadrant II (high-severity psychiatric & low-severity substance use) (n = 25, 16%), and quadrant III (low-severity psychiatric & high-severity substance use) (n = 14, 9%). Quadrant placement was correlated with psychiatric and/or substance use diagnoses, psychiatric symptom severity, drug/alcohol toxicology and psychiatric and substance use health utilization, supporting the concurrent validity of the model. Initial quadrant placement was correlated with validity measures administered at three-month follow-up supporting predictive validity of the model. Initial and follow-up quadrant placement was significantly correlated suggesting stability of the quadrant model. Data support the validity of the quadrant model for application in clinical and administrative purposes.

The collaborative assessment and management of suicidality (CAMS) versus enhanced care as usual (E-CAU) with suicidal soldiers: Moderator analyses from a randomized controlled trial

ABSTRACT Given historically high rates of suicide among military personnel over the past decade the present study analyzed whether key demographic, military, and research-based variables moderated clinical treatment outcomes of 148 suicidal active duty US Army soldiers. This is a secondary analysis of data from a randomized controlled trial comparing the collaborative assessment and management of suicidality (CAMS) to enhanced care as usual (E-CAU; Jobes et al., 2017). Nine potential moderator variables were derived from the suicidology literature, military-specific considerations, and previous CAMS research; these were sex, age, marital status, race, lifetime suicide attempts, combat deployments, time in service, initial distress, and borderline personality disorder diagnosis. The clinical outcomes included six suicide- and mental health-related variables. Six of the eight significant moderator findings in this study showed CAMS outperforming E-CAU in certain subgroups with medium to large effect sizes ranging from 0.48 to 1.50. Collectively, the results suggest that CAMS was associated with the greatest improvement among lower complexity soldier patients, particularly those with lower initial distress and fewer deployments. Those who were married or older generally responded better to CAMS, although the results were not entirely consistent with respect to age. CAMS’s effectiveness for married soldiers and those with lower initial distress was a particularly robust finding that persisted when adjusting more stringently for multiple testing. This study sheds light on several factors associated with the success of CAMS among suicidal soldiers that can assist in matching the treatment to those that may benefit the most.

Adolescent clinical populations and associations between trauma and behavioral and emotional problems.

Objective: Trauma exposure is common during childhood and adolescence and is associated with youth emotional and behavioral problems. The present study adds to the current literature on trauma exposure among adolescent clinical populations by examining the association between trauma exposure and adolescent self-report of emotional and behavioral problems broadly, including internalizing and externalizing symptoms, in addition to the trauma-specific symptoms of posttraumatic stress disorder (PTSD). Method: This study included 94 female (64%) and male (36%) adolescents, ages 13–19, representing 4 clinical populations: those seeking inpatient psychiatry, outpatient psychiatry, residential substance abuse, and outpatient medical services. Adolescents self-reported trauma history and internalizing, externalizing, and PTSD symptoms. Results: Most adolescents reported experiencing at least 1 traumatic event (83%; M = 2.28, SD = 1.83). Multiple regression analyses controlling for age, race/ethnicity, gender, and treatment setting indicated a greater number of types of trauma are associated with externalizing symptoms (&bgr; = .31, p < .01) and PTSD symptoms (&bgr; = .35, p < .01). Conclusion: Trauma is a common experience among adolescents, particularly those presenting for behavioral health services, making trauma-informed care essential in these service delivery settings. Treatment that addresses adolescent risk behaviors and prevents recurrent trauma may be particularly important given the negative impact of multiple traumatic events on developing adolescents.

Pre- versus Postenlistment Timing of First Suicide Attempt as a Predictor of Suicide Risk Factors in an Active Duty Military Population With Suicidal Thoughts

ABSTRACT Objective: This study examines the association of pre- versus post-enlistment timing of first suicide attempt with suicidal ideation, depressive symptoms, single vs. multiple attempts, and highest suicide attempt lethality in an active duty military sample with suicidal thoughts. Method: Data were pooled from baseline assessments of 784 help-seeking Service Members. Results: Adjusting for demographic and military covariates, suicidal ideation was higher for those with a history of suicide attempt. A pre-enlistment suicide attempt was associated with over four times the risk of multiple lifetime attempts. Conclusions: Pre-enlistment suicide attempts are important to assess as they increased risk of multiple attempts.