Crisis Line Facilitation

Veterans Health Administration (VHA) patients are at a significantly elevated risk for fatal
and non-fatal suicide attempts and identifying strategies to reduce the risk of suicidal
behavior among members of the military and Veterans is a high national priority. The VHA has
invested extensively in suicide prevention and, as part of these efforts; the Veterans Crisis
Line was developed as an important resource for Veterans and their families. Utilization of
the Veterans Crisis Line has expanded steadily since it first opened and, currently, it
receives over 20,000 calls per month. Despite high utilization of the Crisis Line, no data
are currently available on whether use of the Veterans Crisis Line reduces an individual's
likelihood of a suicide attempt or death and it is not feasible to test the efficacy of the
Crisis Line in a randomized controlled trial because it is nationally available to all
Veterans and their families. More importantly, the Veterans Crisis Line may not reach those
individuals at most acute risk for suicide. The investigators' study team conducted a small
survey of Veterans treated for recent suicidal crisis in a VHA inpatient psychiatric unit and
found that less than half had ever utilized the Veterans Crisis Line and less than a third
had used it within the past year. Consequently, the investigators have developed and gathered
pilot data on a brief intervention designed to increase utilization of the Veterans Crisis
Line among high risk patients, called Crisis Line Facilitation (CLF). This single-session
intervention involves a discussion of the patient's perceived barriers of crisis line use
during periods of suicidal crisis. The CLF session ends with the patient calling the Crisis
Line with the therapist in the room as a way for Veterans to practice the logistics of making
the call and to have direct experiences that may counter any negative beliefs about Veterans
Crisis Line use. This study recruited 301 participants who were treated for a suicidal crisis
in VHA inpatient psychiatric but had not recently used the Veterans Crisis Line. This study
is a randomized controlled trial of the impact of CLF compared to enhanced usual care (EUC)
on utilization of the Veterans Crisis Line and other mental health services as well as
suicide attempt(s). All participants will be re-assessed at 3-, 6- and 12-months post
baseline. Analyses will also examine the extent to which post-baseline Crisis Line use
mediates the effect of random assignment to CLF on subsequent suicidal behaviors. Qualitative
interviews at the end of the study will help understand barriers and facilitators of future
implementation of the CLF intervention. If successful, the proposed study will provide key
data on the potential efficacy of a brief intervention to improve the utilization of an
existing resource, the Veterans Crisis Line, to reduce suicidal behaviors in VHA patients.
Developing a brief and effective approach to encourage use of the Crisis Line has the
potential to have a significant and substantial impact on suicide rates within the VHA and
could be modified and exported to other populations and settings.

Inclusion Criteria:

Inclusion criteria for screening (Part 1).

- adults age 18 years of age or older receiving care in an inpatient psychiatric unit at
either the BC VAMC or AA VAMC;

- mention of a significant suicidal crisis within the intake note;

- medically stable and able to provide informed consent; and

- Mini-Mental State Examination (MMSE)58 score greater than or equal to 21.

Additional inclusion criteria for the full randomized study (Part 2):

- no reported use of the Veterans Crisis Line within the past 12-months;

- report current suicidal ideation (BSS greater than or equals 5 during the week prior
to hospitalization) as reported during the screening interview.

Exclusion Criteria:

Exclusion criteria for screening and full study:

- patients who do not understand English;

- prisoners;

- patients deemed unable to provide informed consent as stated above;

- patients who recently received or are scheduled to receive electroconvulsive therapy
(ECT); and

- profound psychotic symptoms and/or cognitive deficits that would prevent patients from
understanding the content of the intervention and/or assessments.

- Similar to the investigators' ongoing IIR which recruited from VHA inpatient
units, the investigators do not have explicit exclusion criteria related to
psychotic or cognitive disorders.

- Instead of relying on diagnoses, the investigators will make judgments of
appropriateness for the trial based on the clinical judgment of the study staff
(supplemented with information in the clinical record).

- It has been the investigators' experience that patients often are unable to
provide informed consent early in a psychiatric stay but their status will
improve significantly prior to discharge.

- The investigators attempt to recruit participants during this period of improved
stability and will include individuals who meet the above inclusion/exclusion
criteria at that time.