WHITE RIVER JUNCTION, VT — After 18 months of pandemic disruption and isolation, International organizations are urging governments, health systems and nonprofits to prioritize suicide prevention. The VA may have just the program.
“Suicide is an urgent public health problem, and its prevention must be a national priority,” said Renato Oliveira e Souza, head of the Mental Health Unit at the Pan American Health Organization. “We need concrete action from all elements of society to put an end to these deaths and for governments to create and invest in a comprehensive national strategy to improve suicide prevention and care.”
According to the World Health Organization (WHO), suicide takes more lives each year than malaria, breast cancer or human immunodeficiency virus (HIV). WHO recommends prevention measures, such as reduced access to the means of suicide, early identification of individuals at risk, assessment, management and follow-up of individuals experiencing suicidal thoughts and behaviors.
Impact of COVID-19
Many people worried that COVID-19 would drive up suicide rates among veterans, a group that already had elevated risk of suicide relative to the general population. A study recently published in JAMA Psychiatry found that “rates of suicide ideation and suicide attempts did not significantly increase from prepandemic to peripandemic at the population level,” although 2.6% of the 3,078 veterans in the study did develop new-onset suicidal ideation during the period studied.1
The study used the prospective cohort study from the National Health and Resilience in Veterans Study conducted in November 2019 for the prepandemic data and the survey conducted in November 2020, 10 months after the declaration of the COVID-related U.S. public health emergency, for the peripandemic data. In 2020, 233 veterans (7.8%) reported suicidal ideation in the last year and eight (0.3%) reported a suicide attempt. That was a decrease from the 2019 numbers, where 10.6% of those surveyed indicated past-year suicidal ideation, although 82 veterans reported new-onset ideation in 2020.
“These results suggest that, despite grim forecasts about the COVID-19 pandemic possibly creating a perfect storm for suicidal behavior, the prevalence of suicidality did not appear to increase among military veterans nearly 10 months into the pandemic,” the authors wrote. The researchers suggested that the unexpected result may be attributed to veterans’ greater resilience due to older age and experience with managing adversity.
The highest risk factors for suicidal ideation in 2020 were suicide attempt history (odds ratio [OR], 6.31; 95% CI, 2.71-14.67), low social support (OR, 2.77; 95% CI, 1.46-5.28), COVID-19 infection (OR, 2.41; 95% CI, 1.41-5.01), lifetime posttraumatic stress disorder and/or depression (OR, 2.25; 95% CI, 1.16-4.35), and worsening of social relationships during the pandemic (OR, 1.47; 95% CI, 1.16-1.88).
Given that infection with COVID-19 more than doubled the odds of reporting suicidal ideation, the study “suggests the need for future research to examine the potential link between COVID-19 infection and suicidal behavior,” the authors noted.
Notably, “this study assessed for past-year suicidality at the peripandemic period, but it is possible that suicidal behavior may not emerge until later as a result of compounding problems,” the authors observed in their conclusion.
From WHO to How
While the numbers of veterans experiencing suicidal ideation or attempting suicide did not rise during the first 10 months of the pandemic, some veterans still struggled with suicidal thoughts and the VA continued to work to help them.
At the White River Junction VAMC, another team implemented a pilot trial to prevent suicides. The group had previously conducted a meta-analysis of suicide prevention interventions that included 72 randomized controlled trials and six pooled analyses. Three of the RCTs, with a combined 2,028 participants, found that the WHO’s brief intervention and contact (BIC) was the only program associated with significantly lower odds of suicide (OR = 0.20, 95% CI 0.09-0.42). BIC is a one-hour individual information session close to discharge with a series of follow-up contacts in person or by phone, at regular intervals, by a trained clinician. Six RCTs each of cognitive behavioral therapy and lithium showed nonsignificant lower odds.2
Having concluded that “the WHO BIC is a promising suicide prevention strategy,” the White River Junction researchers targeted the three-month period following a psychiatric hospitalization, when the risk is particularly elevated. “Based on current evidence, some of the most important contributing factors to post-hospitalization suicide risk include problems with engagement in care, fragmented care, and lack of social connectedness,” they noted in describing the clinical trial.
The team first trialed an adapted version of BIC to ascertain its feasibility and acceptability in the setting of a high-income country, as the WHO studies had not included that environment. Nine patients enrolled in the initial pilot. Results reported in late 2019 showed that patients “experienced significant improvements in suicidal ideation, hopelessness and connectedness at one and three months” and were highly satisfied with the approach.3
The team then conducted a randomized control trial of the program they called Prevention of suicide: Education, Awareness, Connection, and Engagement (PEACE), which combined BIC with a mobile mental health app that targets social connectedness. Participants in the BIC/PEACE arm received a one-hour, one-on-one educational session of suicide prevention, plus seven subsequent contacts from the psychologist who provided the educational visit, and a mobile app. Patients in the control arm received recommendations for evidence-based treatment, help developing a safety plan two follow-up care visits within the first month post-discharge and enhanced oversight if they were classified as high risk.4
In the RCT, 10 patients were randomly assigned to the VA BIC variant and nine received standard care. “The VA BIC had a medium or large effect on most measures at one month (suicidal ideation, g=0.45),” the researchers reported. The effects declined by three months, although the thwarted belongingness measure still showed a benefit.
The full trial is anticipated to enroll between 90 and 160 veterans discharged from the White River Junction VAMC inpatient mental health unit over the next several years.
- Nichter B, Hill ML, Na PJ, et al. Prevalence and Trends in Suicidal Behavior Among US Military Veterans During the COVID-19 Pandemic. JAMA Psychiatry. Published online August 25, 2021. doi:10.1001/jamapsychiatry.2021.2332
- Riblet NBV, Shiner B, Young-Xu Y, Watts BV. Strategies to prevent death by suicide: meta-analysis of randomized controlled trials. Br J Psychiatry. 2017 Jun;210(6):396-402. doi: 10.1192/bjp.bp.116.187799. Epub 2017 Apr 20. PMID: 28428338.
- Riblet, Natalie B. MD, MPH∗,†,‡; Shiner, Brian MD, MPH∗,†,‡; Schnurr, Paula PhD†,§; Bruce, Martha L. PhD, MPH†,‡; Wasserman, Danuta MD, PhD∥; Cornelius, Sarah BS∗; Scott, Robert MD, PhD∗,†; Watts, Bradley V. MD, MPH†,∗∗ A Pilot Study of an Intervention to Prevent Suicide After Psychiatric Hospitalization, The Journal of Nervous and Mental Disease: December 2019 – Volume 207 – Issue 12 – p 1031-1038 doi: 10.1097/NMD.0000000000001061
- Riblet NB, Stevens SP, Watts BV, Gui J, Forehand J, Cornelius S, Powell R, Lewicki K, Wasserman D, Shiner B. A Pilot Randomized Trial of a Brief Intervention to Prevent Suicide After Inpatient Psychiatric Discharge. Psychiatr Serv. 2021 May 12:appips202000537. doi: 10.1176/appi.ps.202000537. Epub ahead of print. PMID: 33979200.