Research paperEffect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial☆
Introduction
Due to the rapid rise in U.S. Army suicides (Schoenbaum et al., 2014), interest in developing effective strategies to prevent suicidal behavior in the military has increased. Recent findings indicate that brief cognitive behavioral therapy (CBT), a 12-session outpatient psychotherapy, reduced suicide attempts by 60% in a sample of active duty Soldiers Rudd et al., 2015). Unfortunately, during the month preceding their deaths, Soldiers who die by suicide are much less likely to visit a mental health clinic as they are to visit nonpsychiatric clinical settings (e.g., primary care, family medicine, emergency medicine) (Trofimovich et al., 2012), suggesting the majority of at-risk Soldiers are unlikely to receive such treatments. Suicide rates in the U.S. general population have also risen during the past decade, prompting the Joint Commission to release an updated Sentinel Event Alert focused on the assessment and treatment of suicidal patients across all health care settings (The Joint Commission, 2016). Effective, highly transportable risk management strategies that can be easily implemented are therefore needed.
One widely-used strategy is the contract for safety, also known as the no-suicide contract, which entails eliciting a commitment from the suicidal patient to avoid engaging in suicidal behavior (Simon, 1999, Weiss, 2001, Range et al., 2002, Assey, 1985, Callahan, 1996, Kelly and Knudson, 2000, Kroll, 2000). Despite widespread use across medical disciplines, accumulating consensus is that contracting for safety may be ineffective (Kelly and Knudson, 2000, Reid, 1998, Shaffer and Pfeffer, 2001, Stanford et al., 1994) or potentially even harmful (Shaffer and Pfeffer, 2001, Rudd et al., 2006). The Joint Commission has therefore recommended (The Joint Commission, 2016) alternative strategies such as crisis response planning (Rudd et al., 2006, Bryan, 2010) and the related safety planning intervention (Stanley and Brown, 2012). Written on a small card, crisis response planning outlines steps for identifying one's personal warning signs, using coping strategies, activating social support, and accessing professional services (Rudd et al., 2006, Bryan, 2010, Stanley and Brown, 2012). The crisis response plan therefore outlines what to do during a crisis (i.e., use a range of coping strategies), an approach that sharply contrasts with the contract for safety, which outlines what not to do during a crisis (i.e., engage in suicidal behavior). Like the contract for safety, however, use of crisis response plans is largely based on clinicians’ beliefs about effectiveness rather than actual empirical data (Kelly and Knudson, 2000, Hogan, 2016). Its adoption across psychiatric and nonspsychiatric health care settings (e.g., emergency departments, primary care clinics, inpatient psychiatric units, outpatient psychotherapy) has therefore occurred in the absence of explicit empirical testing.
The primary aim of the current study was to compare the effectiveness of crisis response planning on suicidal thoughts and behaviors during a 6-month follow-up period among active duty Soldiers as compared to supportive counseling with a verbal contract for safety. To this end, our first hypothesis was that crisis response planning would be significantly better than the contract for safety in reducing suicide attempts and suicide ideation. Recent evidence suggests that one mechanism of action contributing to reductions in suicide attempts in brief CBT is the strengthening of the patient's desire to live (Bryan et al., 2016). As such, we additionally sought to determine if the crisis response plan's effects could be enhanced by adding a component designed to clarify the patient's reasons for living. Our second hypothesis was that the enhanced crisis response plan would be significantly better than the standard crisis response plan and the contract for safety.
Section snippets
Participants and procedures
Participants were 97 active duty U.S. Army personnel (78% male) aged 19–53 years (M=26.1, SD=6.4) with active suicide ideation and/or a lifetime history of suicide attempt who voluntarily presented to a military medical clinic for an emergency behavioral health evaluation at Fort Carson, Colorado, from January to December 2013 and January 2015 to February 2016. There was a one-year gap in enrollment from January to December 2014 due to a temporary administrative closure of the study by the
Statistical analysis
All analyses were conducted using an intent-to-treat approach. Primary analyses focused on the effect of treatment group on suicide attempt rates, severity of suicide ideation, and mental health care utilization during follow-up. Estimated proportions of participants in each treatment group who attempted suicide during follow-up were calculated using the Kaplan-Meier method. The log-rank statistic was used for the test of group differences in suicide attempt rates. Hazard ratios were calculated
Suicide attempts
A total of 8 suicide attempts occurred across all treatment groups during the 6-month follow-up, to include one death by suicide in enhanced crisis resposne plan: enhanced crisis response plan, n=2 (estimated proportion: 6.2%); standard crisis response plan n=1 (estimated proportion: 3.1%); and contract for safety, n=5 (estimated proportion: 19.0%). The number and proportion of follow-up suicide attempts by treatment group and study phase were similar across both phases of treatment (see Table 3
Discussion
The focus of this randomized clinical trial was to compare the effectiveness of crisis response planning on the risk for follow-up suicide attempt and suicide ideation among active duty Soldiers presenting to military medical clinics for an emergency behavioral health appointment. Though commonly used across medical settings, the crisis response plan (and the related safety planning intervention) had not yet been definitely tested until now (Hogan, 2016). Consistent with our expectations,
Previous Presentations
European Symposium for Suicide and Suicidal Behavior, Oviedo, Spain, Sep 8–10, 2016.
Disclosures and acknowledgements
Drs. Bryan, Mintz, and Rudd report grant funding from the Department of Defense. Drs. Bryan and Rudd receive compensation for providing training and consultation specific to suicide risk management and the use of crisis response plans. No other disclosures were reported.
Funding/support
This study was supported in part by the Military Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under award #W81XWH-10-2-0181. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the U.S. Government, the Department of Defense, the Department of the Army, or the MSRC.
Role of the Funder/Sponsor
The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Acknowledgement
The authors would like to express their gratitude to AnnaBelle O. Bryan, MS, who assisted with regulatory compliance, records maintenance, and administrative support, and Brian Butler, PhD, who served as the study's medical monitor.
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ClinicalTrials.govIdentifier: NCT02042131