Rapid Personalization of Safety Plans for Psychiatrically Hospitalized Veterans at High-Risk for Suicide

VA Office of Research and Development

Status: Begins enrollment this month

Conditions: Suicide

Treatments: Behavioral: Safety Plans as Usual + Calls; Behavioral: Personalized Safety Plans

Study type: Interventional

Funder types: Other U.S. Federal agency

Identifiers

NCT07507786

IK2RD001575-01A1 (Other Grant/Funding Number)

MHBC-012-25S

Details and patient eligibility

About

Veterans psychiatrically hospitalized face significantly elevated suicide risk, particularly in the three months post-discharge. While Safety Planning is a required component of discharge planning, many safety plans lack personalization thereby reducing their effectiveness. The proposed intervention, Personalized Safety Plans (PSP), will be developed for rapid delivery on acute inpatient psychiatry units. PSP is a single-session intervention followed by twice monthly brief, personalized coaching sessions during the three-month high-risk discharge period. PSP will be iteratively refined and finalized in a case series (N = 15) then evaluated in a pilot randomized controlled trial (N = 96) comparing PSP to Safety Plans as Usual among psychiatrically hospitalized Veterans. Overall, the study aims to: 1) iteratively refine PSP; 2) examine PSP's preliminary effectiveness in reducing suicide ideation and increasing adaptive coping; 3) identify barriers and facilitators to implementation; and 4) develop a fidelity measure to support future personalization monitoring.

Full description

Veterans hospitalized in inpatient psychiatry units are eight times more likely to die by suicide than all Veterans who use VA services, with the highest risk period being the first three months post-discharge. Safety Planning is a required component of discharge planning for psychiatrically hospitalized Veterans, yet many safety plans (SPs) are often poorly personalized which significantly limits their effectiveness. Clinicians need better training to personalize SPs and Veterans prefer a personalized intervention that identifies their specific suicide warning signs and adaptive coping skills. Improvements in SP application are critically needed. To address this gap, the proposed intervention, Personalized Safety Plans (PSP), will be developed for rapid delivery on acute inpatient psychiatry units. PSP is a single-session intervention followed by twice monthly brief, personalized coaching sessions during the three-month high-risk discharge period. PSP will be iteratively refined in a case series (N = 15) and then, consistent with a hybrid I effectiveness-implementation design, evaluated in a pilot randomized controlled trial (RCT; N = 96) comparing PSP to SP as Usual among psychiatrically hospitalized Veterans. In the case series, Veterans will complete assessments at baseline, post-treatment, and at 1 month post-discharge. In the pilot RCT, Veterans will complete assessments at baseline, post-treatment, and at 1, 3, and 6 months post-discharge. The primary goal is to determine PSP's preliminary effectiveness; the secondary goal is to understand the implementation context through feedback from Veterans, clinicians, and stakeholders. The proposed study will provide a foundation for a larger RCT through four aims: 1) iteratively refine PSP, guided by Veteran, clinician, and stakeholder feedback; 2) examine PSP's preliminary effectiveness in reducing suicide ideation, increasing adaptive coping, and increasing SP personalization compared to SP as Usual; 3) identify barriers and facilitators to implementation; and 4) develop a fidelity measure to support future personalization monitoring. The proposed study will be conducted in the Behavioral Science Division of the National Center for PTSD at the VA Boston Healthcare System with support from a collaborative and expert mentorship team. The candidate will pursue five training aims: 1) obtain expertise in treatment adaptation and conducting RCTs with psychiatrically hospitalized Veterans; 2) gain analytic skills to evaluate RCTs; 3) refine clinical expertise in treating suicidal Veterans; 4) acquire fundamentals of implementation science; and 5) engage in professional development to support the transition to an independently funded VA investigator. The proposed study and training directly aligns with the candidate's career goal of becoming a VA clinical trialists who develops, adapts, and tests personalized and implementable interventions to reduce Veteran suicide.

Enrollment: 111 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

Participants will be Veterans who are:

• admitted to VABHS inpatient psychiatry for suicide risk
• display sufficient English comprehension and cognitive capacity to understand the study and provide informed consent
• have been medically cleared by attending physician

Exclusion criteria

The exclusion criteria for Veterans in this study are:

• current psychosis
• current mania
• dementia or other significant cognitive impairment
• being inaccessible and discharged from the unit less than 48 hours after being identified by study staff
• prisoner status

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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111 participants in 2 patient groups

Personalized Safety Plans

Experimental group

Description:

Personalized Safety Plans is a single-session (up to 90min) inpatient intervention followed by twice-monthly coaching sessions (up to 30min each) over the three-month high-risk discharge period. The inpatient session uses chain and solution analyses from Dialectical Behavior Therapy to build a shared understanding of the suicide crisis, including vulnerability factors, prompting events, behavioral links, consequences, and solutions. Veterans also identify distal patterns of suicide risk, supporting proactive risk reduction. Chain and solution analyses populate a personalized, actionable safety plan. Follow-up coaching sessions focus on the Veteran's safety plan, including reviewing its personalization, addressing barriers to in-home use, and making necessary updates. Participants will continue to receive inpatient and outpatient treatment as usual.

Treatment:

Behavioral: Personalized Safety Plans

Safety Plans as Usual + Calls

Active Comparator group

Description:

The comparator condition is Safety Plan as Usual plus attentional control phone calls. Safety Plan as Usual reflect standard clinical practice on the inpatient psychiatry of how safety plans are created. Per VHA Directives and clinical requirements, all at-risk patients must collaboratively develop a SP and receive a copy prior to discharge. Providers use the suicide narrative alongside questions from the Safety Planning Intervention Manual. Attentional control phone calls are twice-monthly supportive check-ins, matched in frequency to the Personalized Safety Plans coaching sessions, designed to control for time and attention differences between conditions. Participants will continue to receive inpatient and outpatient treatment as usual.

Treatment:

Behavioral: Safety Plans as Usual + Calls