Kanchana Perera

Post-Admission Cognitive Therapy (PACT) for the Prevention of Suicide in Military Personnel With Histories of Trauma: Treatment Development and Case Example

To date, no inpatient evidence-based psychotherapeutic interventions have been developed for suicidal individuals with psychological trauma. Therefore, we have adapted, refined, implemented, and pilot-tested an inpatient-based cognitive behavioral therapy protocol, named Post-Admission Cognitive Therapy (PACT), for the prevention of suicide. This article briefly describes the theoretical and research underpinnings for PACT, components of the treatment protocol, and clinical challenges. A case study of a traumatized military service member hospitalized following a suicide attempt is presented. Baseline and follow-up assessment data show general improvements in suicide ideation, depression, hopelessness, and Post Traumatic Stress Disorder symptomatology over time. While the data for the presented case appears promising, the efficacy of PACT remains unknown and is currently under investigation in a randomized controlled trial. Recommendations for clinicians and students who deliver care to suicidal psychiatric inpatients are provided.

Motor impulsivity differentiates between psychiatric inpatients with multiple versus single lifetime suicide attempts

A history of multiple suicide attempts conveys greater risk for suicide than a single attempt. Impulsivity may partially explain the association between multiple attempts and increased risk. We examined trait impulsivity, ability to engage in goal-directed behaviors, and impulse control among psychiatrically hospitalized United States military personnel and their dependents. Individuals with a history of multiple versus single attempts had significantly higher motor impulsivity, indicating spur of the moment action. Providers are encouraged to directly assess and treat motor impulsivity among suicidal individuals. Further research should explore whether motor impulsivity is a mechanism of change in psychosocial suicide prevention interventions.

Retrospective and prospective examination of outpatient mental health utilization and military career impacts.

United States (U.S.) military personnel express concerns about the potential impact of seeking mental health care on their careers. To date, there is a lack of empirical data on the association between mental health treatment utilization at a military treatment facility and career-related outcomes. This study examined short- and long-term military career outcomes among U.S. Air Force (USAF) personnel receiving outpatient mental health care. Phase 1 involved a retrospective chart review (N = 370) across nine USAF mental health outpatient clinics. Phase 2 involved a prospective case control comparison of the career-trajectories of USAF personnel who sought mental health treatment (n = 332) versus those who did not (n = 1147) after matching for military rank, time in grade, and occupational code. Overall, nearly a third of service members received career-affecting recommendations from their mental health treatment provider. Commander-directed service members were more likely to receive career-affecting recommendations than those self-referred or superior-encouraged. Younger age, higher rank, superior-encouraged referral, greater self-reported distress during first contact, and history of psychiatric inpatient care were predictors of receiving career-affecting recommendations. Service members receiving outpatient mental health care, compared to those without a military history of mental health care, were three times more likely to experience a medical board evaluation and nearly twice as likely to receive a discharge. Proactive, early self-referral for mental health treatment is one strategy for sustaining a military career. Department of Defense stigma reduction campaigns should provide empirically derived information about mental health treatment utilization and military career-related outcomes.

Outpatient Mental Health Treatment Utilization and Military Career Impact in the United States Marine Corps

Service members (SM) are at increased risk of psychiatric conditions, including suicide, yet research indicates SMs believe seeking mental health treatment may negatively impact their military careers, despite a paucity of research examining actual career impacts. This study examined the link between seeking outpatient mental health (MH) treatment and military career impacts within the United States Marine Corps. In Phase 1, a retrospective medical record review of outpatient MH treatment-seeking Marines (N = 38) was conducted. In Phase 2, a sample of outpatient MH treatment-seeking Marines (N = 40) was matched to a non-treatment-seeking sample of Marines (N = 138) to compare career-progression. In Phase 1, there were no significant links between demographic, military, and clinical characteristics and referral source or receipt of career-affecting treatment recommendations. In Phase 2, MH treatment-seeking Marines in outpatient settings were more likely than matched controls to be separated from the military (95.0% versus 63.0%, p = 0.002), but no more likely to experience involuntary separation. MH treatment-seeking Marines were more likely to have documented legal action (45.0% versus 23.9%, p = 0.008) and had a shorter time of military service following the index MH encounter than matched controls (p < 0.001). Clinical, anti-stigma, and suicide prevention policy implications are discussed.

The Link between Posttraumatic Stress Disorder and Functionality among United States Military Service Members Psychiatrically Hospitalized Following a Suicide Crisis

Posttraumatic stress disorder (PTSD) is one of the most commonly diagnosed psychiatric disorders in the United States and has been linked to suicidal thoughts and behaviors, yet the role of a PTSD diagnosis on functional impairment among suicidal individuals remains unknown. This study examined the association between PTSD status and functional impairment among military psychiatric inpatients admitted for acute suicide risk (N = 166) with a lifetime history of at least one suicide attempt. Measures of functionality included: (1) alcohol use; (2) sleep quality; (3) social problem-solving; and (4) work and social adjustment. Thirty-eight percent of the sample met criteria for PTSD. Women were more likely than men to meet criteria for PTSD (p = 0.007), and participants who met PTSD criteria had significantly more psychiatric diagnoses (p < 0.001). Service members who met PTSD criteria reported more disturbed sleep (p = 0.003) and greater difficulties with work and social adjustment (p = 0.004) than those who did not meet PTSD criteria. However, functionality measures were not significantly associated with PTSD status after controlling for gender and psychiatric comorbidity. Gender and number of psychiatric comorbidities other than PTSD were significant predictors of PTSD in logistic regression models across four functionality measures. Future studies should assess the additive or mediating effect of psychiatric comorbidities in the association between impaired functioning and PTSD. Clinicians are encouraged to assess and address functionality during treatment with suicidal individuals, paying particular attention to individuals with multiple psychiatric diagnoses.

Non-Suicidal Self-Injury Elevates Suicide Risk among United States Military Personnel with Lifetime Attempted Suicide

Military psychiatric inpatients with and without a lifetime history of non-suicidal self-injury (NSSI), combined with a history of at least one suicide attempt, were compared on suicide ideation severity, number of suicide attempts, and Interpersonal-Psychological Theory of Suicide variables. Data were derived from baseline assessments performed in a psychotherapy randomized controlled trial. Lifetime history of NSSI and lifetime number of suicide attempts were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011). Individuals with versus without a combined lifetime history of attempted suicide and NSSI showed significant elevations on thwarted belongingness and acquired capability for suicide. No significant between-group differences were found on perceived burdensomeness, frequency, duration, and controllability of suicide ideation, or number of lifetime suicide attempts. A history of NSSI, above and beyond attempted suicide, appears to increase service members’ social alienation and acquired capability for suicide.

Perspectives of Suicide Bereaved Individuals on Military Suicide Decedents’ Life Stressors and Male Gender Role Stress

The objective of this study was to pilot the newly developed Male Gender Role Stressor Inventory (MGRSI) in military suicide bereaved (i.e., decedents’ family members and significant others) and to determine the association between Male Gender Role Stress (MGRS) and other life stressors observed by survivors. Sixty-five survivors attending a national survivor seminar completed original surveys, reporting demographic information about themselves and the decedent and observations of the decedents life stressors during the 1-month and 1-year periods prior to death. The MGRSI obtained acceptable internal reliability (α = .76) and indicated that factors including honor, strength, and achievement were the most commonly reported sources of MGRS. Correlational and regression analyses revealed that legal- and trauma-related stressors 1 month prior to suicide were significantly associated with MGRSI score. MGRS may contribute to a better understanding of military male suicide. The Department of Defense and the Veterans Administration may benefit from suicide prevention programs targeting rigid male gender role beliefs and male-specific stressors.

Perceived barriers to seeking mental health care among United States Marine Corps noncommissioned officers serving as gatekeepers for suicide prevention

Reducing mental health stigma and perceived barriers to care is a necessary strategy for addressing the public health problem of suicide among the United States Armed Forces. The purpose of this study was threefold: (a) to empirically evaluate the principal component structure of the Perceived Barriers to Care (PBTC) measure; (b) to gain an understanding of the perceived barriers to seeking mental health services among Marine Corps noncommissioned officers (NCOs) selected to participate in a primary suicide prevention training program, Never Leave a Marine Behind (NLMB); and (c) to explore the relationship among sex, education, prior exposure to suicide within ones military unit, and perceived barriers to seeking mental health services. The data for the PBTC (N = 1,758) were drawn from a previously performed pretest/posttest program evaluation study of the Marine Corps NLMB program, which took place over 6 months in 2009 (April-October). The three highest perceptions of barriers to care reported by NCOs for their Marines were related to being embarrassed, having members of ones unit have less confidence in the Marine, and concerns about being treated differently by military unit leadership. Three principal components for PBTC were identified, accounting for approximately 59% of the total variance. Higher education and prior exposure to suicide within ones military unit significantly correlated with greater perceived barriers to care; sex was not significantly correlated with greater perceived barriers to care. Implications of these findings, in relation to future research, are further discussed. (PsycINFO Database Record

How Parental Reactions Change in Response to Adolescent Suicide Attempt

This study examined parental reactions to adolescents’ suicide attempts and the association of reactions with future suicidal self-directed violence. Participants were 81 mothers and 49 fathers of 85 psychiatric inpatient adolescents. Maternal hostility and paternal anger and arguing predicted future suicide attempts. From pre- to post-attempt, mothers reported feeling increased sadness, caring, anxiety, guilt, fear, and being overwhelmed; fathers reported increased sadness, anxiety, and fear. Findings have clinical implications; improving parent-child relationships post-suicide attempt may serve as a protective factor for suicide.

Pilot trial of post-admission cognitive therapy: Inpatient program for suicide prevention.

Suicide remains a significant public health problem for the United States military. Trauma-related diagnoses such as acute stress disorder (ASD) or posttraumatic stress disorder (PTSD) may exacerbate suicide risk, particularly among service members psychiatrically hospitalized following suicide-related events. To date, treatments to address suicide risk and trauma symptomatology among service members within inpatient milieus have been nonexistent. To address this gap, a randomized controlled pilot trial of Post-Admission Cognitive Therapy (PACT) was conducted to evaluate a targeted cognitive-behavioral program among traumatized military personnel (N = 36) hospitalized following a recent suicide attempt. All participants met criteria for ASD or PTSD and were randomly assigned to receive either PACT and enhanced usual care (PACT + EUC) or EUC alone. PACT consisted of six 60- to 90-min individual psychotherapy sessions, adapted from Brown et al.’s (2005) cognitive therapy protocol for suicide prevention. Blinded follow-up assessments were conducted at 1-, 2-, and 3-months postpsychiatric discharge. The primary outcome was days until repeat suicide attempt. Secondary outcomes included depression, hopelessness, suicide ideation, and PTSD symptoms. Participants did not significantly differ in reattempt status. However, based on reliable change index analyses, a greater proportion of PACT + EUC versus EUC participants met criteria for clinically significant change on measures of depression (100% vs. 78%), hopelessness (83% vs. 57%), and PTSD symptom severity (100% vs. 38%), but not for suicide ideation (60% vs. 67%). PACT is an innovative inpatient protocol, currently under evaluation in a well-powered multisite RCT for its efficacy in reducing subsequent suicidal behaviors.