Statement of the Problem: Reducing suicide in rural Veterans is a high priority for VHA’s broader suicide prevention efforts, given this group’s higher risk of suicide (20-22% higher than non-rural Veterans). Several challenges need to be overcome to provide evidence-based suicide prevention to Veterans in rural areas. First, empirical support for interventions that reduce suicide in Veterans overall is very limited. Second, although telehealth can overcome structural access barriers, provider misgivings about the use of telehealth for suicidal individuals will need to be addressed to enhance widespread use of this technology for suicide prevention. Proposed Innovation To overcome these challenges, the proposed project began with a new evidence-based intervention to prevent suicide— Mindfulness-Based Cognitive Therapy for Suicide Prevention (MBCT-S). Year 1 began with adapting MBCT-S for telehealth delivery, thereby allowing for safe and feasible remote delivery of MBCT-S in rural areas. To address provider concerns with telehealth suicide prevention and thereby enhance potential for MBCT-S adoption, we developed a dissemination-implementation package that includes detailed practice guidelines and procedures, educational materials, a training curriculum, and ongoing consultation and facilitation. This MBCT-S is now being implemented at geographic areas serving rural Veterans in: 1) New York state; 2) Eastern Texas; 3) New Jersey (state rurality criteria or >1 hour total travel distance). In our previous randomized controlled trial (n=140) with Veterans at high risk for suicide, MBCT-S was delivered face-to-face and significantly reduced suicide attempts by approximately half in 12-months, relative to VHA enhanced treatment-as-usual (p=.04). These results showed that, for every 7-8 high-risk Veterans who participated in MBCT-S, one suicide attempt was prevented (NNT=7.5). MBCT-S also significantly reduced acute psychiatric hospitalizations (p=.04, NNT=6.0) in a 12-month period. Project

Objectives: The proposed continuation project builds on significant progress during Years 1-3 to provide MBCT-S to rural Veterans at risk for suicide. The following objectives describe the projects progression towards overcoming rural barriers to suicide prevention care, provider barriers to adopting telehealth suicide prevention, and to set the stage for wide-scale dissemination and implementation. • Objective 1 (Year 1-2)—Develop practice guidelines for telehealth delivery of MBCT-S and provide to 60 Veterans at risk for suicide. • Objective 2 (Year 2-3)— Develop telehealth MBCT-S dissemination framework including training and consultation. • Objective 3 (Year 2-4)—Implement MBCT-S at VA facilities serving rural Veterans • Objective 3a—VA NYH serving rural Veterans in Upstate NY (45 Veterans annually). • Objective 3b—VA Houston serving rural Veterans in Eastern TX (45 Veterans annually). • Objective 4 (Years 1-4)—Evaluate implementation and effectiveness outcomes using RE AIM Framework (Reach [%reached], Effectiveness [e.g., reduced suicidal ideation, depression] Adoption (# providers referring & delivering), Implementation (barriers & facilitators; training effectiveness, fidelity); Maintenance (site sustainment indicators). Long-term Impact: The proposed project will set the stage for wide-scale implementation of MBCT-S to rural Veterans. The resulting dissemination package will allow MBCT-S to be implemented at other rural VA facilities throughout the U.S. The RE-AIM framework will be utilized to monitor and improve implementation, as well as gather “lessons learned” to guide future expansion of this innovation.

Aim 1: Examine the ongoing implementation of the Suicide Risk Management Consultation Program (SRM). a. Describe the growth and reach of SRM to VA and community providers who serve Veterans at risk for suicide. Aim 2: Describe the characteristics of the consultations conducted through the SRM. a. Describe the providers who consult with us. b. Describe the topics discussed and resources sent c. Describe the population of Veterans for whom consultation is sought. Aim 3: Identify the impact of SRM consultation. a. Describe outcomes for providers who utilize SRM including evaluating the impact of consultation on confidence with and implementation of risk assessment and management strategies for at-risk Veterans. b. Describe the outcomes for SRM consultants specific to confidence as subject matter experts and fidelity to the SRM model.

Veterans Health Administration (VHA) created a Veterans Crisis Line (VCL) as a 24-hour point of contact for Veterans who are at high-risk for suicide. There is a paucity of research on the potential impact of VCL interventions and a need to examine the use of emergency dispatches (i.e., 911) because of their life- saving potential and possible negative consequences.

Significance/Impact: The study examines the potential impact of VCL initiated emergency dispatches on critical outcomes among VCL callers who are at high risk for suicide. It responds to the President's Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) and the HSR&D (HX-19-004) Targeted Solicitation for Health Services Research on Veteran Suicide Prevention.

Innovation: The study will involve the first analyses to link VHA databases to examine the associations of emergency dispatches with critical outcomes and obtain Veterans' and responders' experiences with emergency dispatches. Specific Aims: Aim 1: Determine the association of an emergency dispatch with suicide deaths. Objectives are to 1a) identify key correlates of receiving an emergency dispatch, 1b) determine the association of emergency dispatch with treatment engagement within 30-days, and 1c) risk for suicide death over 365 days. We expect an emergency dispatch to be associated with higher treatment engagement (H1) and lower risk for suicide deaths (H2). Aim 2: Determine the association of agreeing to receive an emergency dispatch with combined suicide deaths and attempts. Objectives are to 2a) identify key correlates of agreeing to the dispatch, 2b) determine the association of agreement with treatment engagement within 30 days, and 2c) risk for combined suicide deaths and attempts over 365 days. We expect caller agreement with an emergency dispatch to be associated with higher treatment engagement (H3) and lower risk for combined suicide deaths and attempts (H4). Aim 3: Explore the experiences of Veteran VCL callers who receive and responders who initiate emergency dispatches. Objectives are to 3a) gather data on Veterans' experiences with the call, emergency dispatch, and subsequent care, 3b) gather data on responder experiences initiating emergency dispatches, and 3c) identify potential improvements in emergency dispatch policy and measurement. Methodology: Quantitative analyses will examine key correlates of emergency dispatches and agreement, and their prospective associations with treatment engagement and suicide outcomes. Qualitative interviews with Veteran callers and VCL responders will be used to understand their experiences with emergency dispatches, evaluate the ecological validity of quantitative findings and inform policy and research.

Implementation/Next Steps: Findings will be presented to Veteran stakeholders and VCL leadership and responders to identify potential policy changes and variables that should be measured for future research. They may also contribute to research on implementing new emergency dispatch procedures across VCL sites.

1) Examine the safety, feasibility and tolerability of frontal pole intermittent theta burst stimulation for Veterans with mild traumatic brain injury, impulsivity and suicidal ideation, 2) Determine the preliminary effects of frontal pole iTBS on social and occupational functioning, impulsivity and SI and 3) evaluate itbs-induced neural connectivity changes between the VMPFC and limbic system

1. At four VHA medical centers, randomize a total of N=254 Veterans with recent suicide attempt and emotion dysregulation to DBT-SG + TAU or TAU alone to evaluate DBT-SG effectiveness. Relative to TAU alone, we hypothesize that at 18-month follow-up, participants in DBT-SG will show: (H1a, primary outcome) reduced number of suicide attempts; (H1b) increased survival time for suicide attempt; (H1c) reduced suicidal ideation. We will also explore condition differences in putative changes in emotion dysregulation and coping skills. 2. Conduct a 3-part formative evaluation, guided by the I-PARiHS framework, to identify DBT-SG implementation barriers and facilitators in outpatient mental health clinics at four VHA medical centers before, during, and after the effectiveness trial. At each phase of the formative evaluation (developmental, process, and post-evaluation), we will seek the input of 60 key clinical, administrative, leadership, and Veteran stakeholders using mixed qualitative-quantitative methods to identify how factors such as evidence for DBT-SG, inner and outer context, recipient characteristics, and facilitation capacity impede or assist DBT-SG implementation.

A Novel Peer-Delivered Recovery-Focused Suicide Prevention Intervention for Veterans with Serious Mental Illness

Aim 1: Evaluate the bivariate association between altitude and death by suicide, suicide attempts, and suicidal ideation at the individual level, including identification of the level of altitude most strongly associated with suicide and suicidal behavior in Veterans. Aim 2: Identify geographic features and social determinants of health that are predictive of: (1) Higher levels of Veteran suicide; and (2) Living at higher levels of altitude. Aim 3: Identify individual-level features from the EHR that best distinguish Veterans who live at higher altitudes from Veterans who live at lower altitudes. Aim 4: Utilize advanced statistical approaches to develop a “hybrid” predictive model of Veteran suicide derived from both individual-leave and geospatial features, including altitude.

Aim 1: Examine the implementation of the Suicide Risk Management Consultation Program (SRMCP). Specifically, we will examine the acceptability and feasibility of the program. Aim 2: Describe the characteristics of the consultations conducted through the SRMCP. a. Describe the providers who consult with us. b. Describe the population of Veterans for whom consultation is sought. Aim 3: Identify knowledge gaps regarding suicide risk assessment and management among providers serving at-risk Veterans.

AIM 1: Identify contextual factors that may inform development of the intervention.; AIM 2: Leverage the expertise of a diverse sample of stakeholders to refine intervention elements, adapt them for use among Veteranse and within VHA EDs, and develop a final intervention protocol and related materials. ; AIM 3: Pilot the ED-based LMS intervention among 40 Veterans to assess feasibility and acceptability. 

Aim 1: Identify Social Determinents of Mental Health via NLP. Aim 2: Compare the relative benefits of alternative NLP approaches, based on accuracy, imporved measurement over only structured data and implementation complexity. Aim 3: Integrate into OMHSP decision support dashboards and predictive analytics (e.g., STORM/RV). Work is occuring on ROCKIES and VINCI. *****ROCKIES concepts include: (1) Loneliness, (2) Access to Lethal Means (3) Intravenous Drug Use, (4) Detoxification Therapy, (5) Justice-involved, (6) Premil/Mil/Postmilitary Sexual Trauma, (7) Food Insecurity, and (8) Job Instability. *****VINCI concepts include: (1) Inter-personel Relationships, (2) Social Connectedness.

Aim 1: In a national, stratified random sample of Veterans screened in primary care and specialty mental health settings, using quantitative surveys, characterize Veteran experiences with the VA Risk-ID screening process and clinical evaluation that takes place in response to screen results. Aim 2: Conduct semi-structured qualitative interviews with A) Veterans who participate in the three stages of VA Risk-ID screening; and B) clinical staff who participate in the three stages of screening. The analysis will prioritize identification of ways to improve screening and patient engagement in treatment after screening. Aim 3: Among Veterans screened with VA Risk-ID in primary care, examine the extent to which screening process and survey variables are associated with mental health treatment utilization variables over 6 months. Aim 4: A) In a national, stratified random sample of Veterans screened in emergency departments (EDs), using mixed methods, characterize Veteran experiences with the VA Risk-ID screening process and clinical evaluation that takes place in response to screen results; B) Among Veterans screened with VA Risk-ID in EDs, examine the extent to which screening process and survey variables are associated with mental health treatment utilization variables over 6 months.

Anhedonia and amotivation are common in depressive presentations, and putatively thought to be caused by alterations in the ways in which the brain anticipates, evaluates, and adaptively uses reward-related information. However, reward processing is a complex, multi-circuit phenomenon, and the precise neural mechanisms that contribute to the absence or reduction of typical hedonic and motivational outputs seen in the clinic are still being elucidated. Heterogeneity in the clinical presentation of depression has long been a rule rather than an exception, including individual variation in symptoms, severity, and treatment response. This heterogeneity complicates understanding of depressive pathophysiology and thwarts progress toward personalized disease classification and treatment planning. If the goal of personalized medicine in psychiatric care is to be realized, biomarkers that account for the full range of depressive presentations need to be developed (and ultimately validated). Discovery of biomarkers that go beyond the level of aggregate disease definitions to account for neurobiological variation that presumably underlies distinct clinical manifestations is critical to this larger effort. The proposed work combines clinically motivated questions with in-depth study of neurobiological mechanisms to evaluate how reward system neurobiology contributes to expression of reward-related deficits, such as anhedonia and amotivation in major depressive disorder (MDD), with a particular emphasis on understanding depressive heterogeneity. Conceptually, we will use a multi-measure approach, by studying Veterans with i) a passive slot machine reward task to isolate brain responses to reward anticipation and receipt in the absence of confounding higher-order cognitive demands, and ii) a delay-discounting task to assess higher-order aspects of reward processing necessary for reward valuation and decision-making. Methodologically, we will use a multi-modality approach by combining fMRI, EEG, and behavioral assessment, to more fully characterize reward-related brain functions and their clinical correlates. In addition to evaluating reward effects between Veterans with MDD and healthy controls (HC), and examining depressive heterogeneity within a large (n=150) MDD group, we will also focus on understanding the relationship between reward processing and clinical features of high relevance to depression, with an emphasis on suicidality. Specific Aim 1 will establish MDD deficits in reward processing at the level of group averages (i.e., case-control comparisons of MDD vs. HC). Specific Aim 2 will examine the extent to which data-driven subtyping of MDD can derive "biotypes" in Veterans, based on our EEG and fMRI reward processing metrics, that segregate clinically relevant features. Specific Aim 3 will compare subgroups of MDD with varying levels of suicidality.

Approximately 800,000 people die from suicide each year and the recent data show that the suicide rate in the United States has increased 33% from 1999 to 2017. United States military veterans have an increased risk of suicide compared with the general population, and approximately 18 to 22 veterans die from suicide each day. It has been reported that up to 90% of individuals who complete suicide have an underlying psychiatric disorder. Suicidal ideation in war veterans is often associated with post-traumatic disorder (PTSD) or depression, conditions that often coexist. In addition, as a fundamental factor in the provocation of depression, chronic stress is associated with suicidal thoughts and behaviors. Also, a history of prior exposure to trauma or to chronic stress is an extremely potent risk factor for PTSD. In preclinical models, chronic stress has been shown to induce changes in behavioral paradigms that can be used to measure aspects of suicidal behavior such as impulsive, aggressive, and depressive-like behaviors. Recent evidence indicate that inflammation, as manifested by increased levels of pro‐inflammatory cytokines, contributes to the pathophysiology of suicidality. However, there is a critical need for studies that are designed to determine the role of specific components of the immune system in suicidal behavior in order to identify novel therapeutic targets. The complement system is part of the innate arm of immunity, but also regulates many aspects of the adaptive immune response. Complement can be activated via the classical, lectin or alternative pathway with complement component 3 (C3) as the converging point of the activation pathways. Our recent study showed an important role of C3 in chronic stress-induced depressive-like behavior in mice. However, it is not known whether chronic stress- induced complement activation mediates suicidal behavior. We hypothesize that classical pathway mediates stress-induced complement activation leading to suicidal behavior. In supporting this, our published and preliminary studies found that (1) C3 and C1qa (a key component of classical pathway) are highly expressed in the prefrontal cortex (PFC) of depressed suicide subjects; 2) exposure to chronic stress conditions induces increases in C1qa and C3 protein levels in mouse PFC; and (3) inhibition of C3 by gene knockout (C3 KO) significantly ameliorated chronic stress-induced aggressive and depressive-like behavior, and infiltration of monocytes into mouse PFC. To further understand the role of complement activation in suicidal behavior, we propose the three Specific Aims to 1) determine the role of complement activation pathway in suicide (with depression or PTSD diagnosis) subjects; 2) investigate whether complement classical pathway is critical to stress-induced suicidal behavior; and 3) determine whether central complement system mediates stress- induced suicidal behavior. Given the important role of immune pathways in suicidal behavior, identifying novel regulatory mechanisms may provide avenues to develop newer therapeutics for suicidal behavior.

Background. Firearm injury accounts for 70% of Veteran suicides, making safer storage of firearms among Veterans at risk for suicide a top VA & HSR&D priority. Although VA providers encourage Veterans to store their firearms more safely during lethal means safety counseling (LMSC), only about half of individuals follow through on these recommendations. Additionally, little is known about methods for verifying firearm storage practices, which are critical for evaluating LMSC interventions. Research shows that offering financial and social incentives increases behavior change, and the Philadelphia VAMC has led a successful national program providing incentive-based interventions to Veterans with substance use disorders. The use of financial and social incentives to increase safe storage of firearms, however, has not yet been assessed. Significance/Impact. This proposal aims to leverage financial and social incentives to increase Veterans' safe storage of firearms following LMSC, thereby contributing to VA's suicide prevention efforts. VA's existing infrastructure supporting the delivery of both LMSC and incentive-based interventions makes it an ideal setting for this work. Operational partners, including the Office of Mental Health and Suicide Prevention, the Rocky Mountain VA, and the Veterans Rural Health Resource Center support this proposal. Innovation. Financial and social incentives increase behavior change and our pilot work suggests that Veterans and VA clinicians are interested in using incentives to encourage safer storage of firearms. This proposal is the first to examine the use of incentives to change firearm storage behavior. It is also the first to evaluate methods for verifying firearm storage practices, which will provide critical information to researchers developing lethal means safety interventions and clinical providers delivering these interventions. Specific Aims. 1) Consult with stakeholders to determine the most acceptable and feasible intervention protocol that offers Veterans at risk for suicide financial and/or social incentives to store their firearms safely. 2) Pilot test the add-on, incentive-based intervention among Veterans receiving LMSC in VA behavioral health. Methodology. Aims will include participants from the VAMCs in Philadelphia and New Orleans, and will be conducted remotely to facilitate recruitment. Veteran participants will be seen in outpatient behavioral health and have access to firearms; equal numbers will be drawn from urban and rural settings and about a quarter will identify as women and racial/ethnic minorities. Aim 1 will include two steps. First, we will conduct qualitative interviews with ~20 Veterans with recent suicidal ideation, as well as ~10 VA clinicians/administrators. Interviews will evaluate the acceptability and feasibility of potential incentives, methods of verifying firearm storage practices, and other intervention components. Second, we will develop an advisory board made up of 8 Veterans and 8 other stakeholders (subject matter experts, VA clinicians/administrators). The advisory board will consider findings from qualitative interviews and use online modified Delphi methods to reach consensus on the most acceptable intervention components and best items to include in the pilot trial outcome measures. The study team will develop an intervention protocol and iteratively modify it to align with study findings. In Aim 2, we will conduct a pilot study with 24 Veterans who have completed LMSC to assess the add-on, incentive- based intervention. We will evaluate the feasibility of recruitment, retainment, provision of incentives, and methods of verifying changes in firearm storage, the acceptability of the intervention, and methods of individualizing the intervention based on Veterans' preferences and sociodemographic characteristics. Next Steps/Implementation. We will apply for IIR funding to conduct a multi-site, Hybrid Effectiveness- Implementation Type 1 Randomized Clinical Trial. This trial will assess the effectiveness of the add-on LMSC intervention and barriers and facilitators to its implementation. If effective, we will disseminate the intervention in VA behavioral health settings to improve safe storage of firearms among Veterans at risk for suicide.

Background: A growing number of Veterans are presenting to the Veterans Health Administration (VHA) for the treatment of Bipolar disorder (BP) and co-occurring substance use disorders (SUDs), with prevalence of SUDs in patients with BP up to 60%. This comorbidity is associated with increased symptom severity, poorer treatment outcomes, and greater use of costly health services such as psychiatric hospitalization.

Significance/Impact: Veterans who transition from psychiatric hospitalization to outpatient care are at heightened risk for treatment nonadherence, mood/substance relapse, deaths due to opioid overdose, and suicide. Nonadherence to treatment is a significant problem among patients with BP, which is further magnified among those with SUDs. Nonadherence leads to increased need for psychiatric readmission, with BP patients recently discharged from inpatient care particularly likely to discontinue pharmacotherapy, relapse to substances, and attempt suicide. Of particular concern are disproportionately greater rates of suicide in Veterans with BP relative to those with other mental health conditions. Veterans with BP who use substances, particularly alcohol and opioids, have the highest suicidality and mortality rates. To date, there is little research on effective and feasible behavioral aftercare interventions designed to improve treatment adherence in this high-risk, comorbid population at the critical period following hospital discharge.

Innovation: Empirical work suggests that the “Integrated Treatment Adherence Program” (ITAP) may be an ideal therapeutic approach to improve treatment adherence and clinical outcomes in Veterans at the critical period of transition to outpatient care following hospitalization. ITAP is an innovative psychosocial intervention developed by our team designed to improve treatment adherence and reduce suicidality, bipolar symptoms, and substance abuse among high-risk patients, addressing HSR&D major research priorities. ITAP combines in-person engagement sessions with follow-up phone contacts and significant other involvement as an adjunct to treatment as usual over 6 months post-hospitalization. Methodology: The proposed Hybrid Type 1 Effectiveness-Implementation Trial will evaluate the effectiveness of ITAP in a sample of 140 Veterans with BP-SUD, randomized to receive either the ITAP intervention or a Safety Assessment and Follow-up Evaluation (SAFE) comparison condition, both delivered as adjuncts to VHA treatment as usual. Veterans will be recruited from the Providence VAMC inpatient psychiatric unit and assessed at baseline and at 3 (mid-treatment), 6 (post-treatment), and 9-month follow-up. The Primary Aim is to test the hypotheses that participants randomized to receive ITAP, relative to SAFE, will evidence improved treatment outcomes at post- treatment, maintained through follow-up. Primary outcomes are: 1) greater treatment adherence defined by (a) percent missed medications doses/month (based on electronic monitoring) and (b) percent missed VHA mental health appointments/month. Secondary outcomes are: (2) reduced suicidality and number of psychiatric hospitalizations/ER visits; and (3) lower depressive and manic symptoms, lower percentage of alcohol and drug use days, and improved overall psychosocial functioning. The Secondary Aims are to identify the mechanisms of action targeted by ITAP, moderators of treatment effects, and perceptions of key stakeholders and contextual factors that may reduce barriers and increase organizational readiness for implementation of ITAP in the VHA. Next Steps/Implementation: If shown effective and in cooperation with our operational partners, the next steps for ITAP would be to conduct a Hybrid Type 3 Implementation Trial to test specific implementation strategies within a multi-site study and to develop an implementation blueprint for ITAP-based standard of care within the VHA. Determining whether ITAP is an effective adjunctive treatment directly addresses the need for improved adherence to evidence-based mental health and substance use treatments and the need for effective suicide prevention interventions in Veterans. Should ITAP prove effective, we will work with our operational partners to prioritize ITAP’s ultimate dissemination and implementation within VHA.

Background: Approximately 200K transitioning service members/Veterans (TSMVs) separate from the military annually and they face elevated suicide risk levels for at least six years after separation. Suicide risk is greatest for those with the most difficulty reintegrating into civilian life roles at home, work, and in the community. Current research on the military-to-civilian reintegration process suffers from a lack of systematized measurement, longitudinal studies, and attention to modifiable factors that influence how individuals respond to disruptive life events. This CDA-1 proposal will leverage longitudinal data from a VA research repository to address these gaps by conducting the first in-depth psychometric investigation of the Military-to-Civilian Questionnaire (M2CQ), followed by an investigation of how reintegration difficulties develop over time. Further, it will evaluate DSM-5 personality functioning as a modifiable predictor of reintegration challenges and subsequent suicide risk during the transition period.

Significance: Rehabilitation is relevant to the reintegration of all TSMVs, who share the goal of adapting to post- military life roles. This CDA-1 will deliver recommendations for assessing reintegration and yield critical insights for identifying TSMVs prone to reintegration difficulty. These are essential steps for detecting intervention targets that promote positive functional outcomes and disrupt suicide risk trajectories. Identifying modifiable predictors of reintegration difficulty will inform a future CDA-2 application focused on developing targeted interventions to address those factors. This CDA-1 is aligned with priorities outlined by the White House's National Strategy for Preventing Veteran Suicide and the VA's National Roadmap to Empower Veterans and End Suicide. This project is also responsive to RR&D's request for suicide prevention research that involves Veterans not currently receiving VA healthcare. Innovativeness: The proposed research represents the first comprehensive psychometric evaluation of the M2CQ in a longitudinal sample of TSMVs. Second, by incorporating the construct of personality functioning, it suggests new ways of thinking about reintegration difficulty and its relationship to suicide risk. Third, the longitudinal design includes pre- and post-transition timepoints, which provide a unique opportunity to directly evaluate temporal changes in reintegration difficulties as a function of co-occurring personality functioning problems and the major life event of separation from service. Specific Aims: Aim 1 is (a) to investigate the M2CQ's structural validity, reliability, and item-level properties; (2) evaluate how well M2CQ scores/items detect meaningful and expected change in functioning over time; (3) to determine whether total scores and items have particularly strong associations with negative clinical outcomes. Aim 2 is to evaluate personality functioning as a potentially modifiable individual difference factor that is associated with reintegration difficulties. Aim 3 is to examine alternative hypotheses about the roles of reintegration difficulty, personality functioning, and psychopathology in predicting future suicidal thoughts and behavior during the military transition period. Methodology: This CDA-1 will use a longitudinal sample of TSMVs who participated in two ongoing community reintegration peer-sponsorship programs. Four waves of data were collected over a one-year period (n = ~ 515): 6- and 2-months before separation; 2- and 6-months post-separation. Statistical analyses include factor analysis, item response theory, and latent growth curve modeling. Next Steps/Implementation: Research results and recommendations for assessing reintegration difficulty will be shared with the VA research and clinical community.

Background: As part of comprehensive suicide prevention, VA integrated mental and physical health services to better detect and treat depression. Primary care nurses conduct screening annually. Clinicians, including Primary Care Mental Health Integration (PC-MHI) specialists, follow up as-needed for treatment. Depression detection and management processes are complex, involve multilevel stakeholders, and subject to significant disruption from COVID-19 and from resulting expansion of telehealth aiming to preserve care access. Fewer VA visits during the pandemic may signify lowered depression care quality and worsened patient outcomes.

Significance: Depression affects 1 in 5 Veterans and is a leading cause of suicidality and disability. It contributes substantially to the current pandemic-related mental health crisis. Depression symptoms, including suicidal thoughts/behaviors, and related functional impairment have increased since COVID onset. Partnering with Primary Care, Mental Health, and Connected Care leaders, we propose to study pandemic-related service disruptions for depression, which may help to mitigate acute care use and mortality in the Veteran population. We apply established depression quality indicators from our prior research to a broad national scale at a critical time. We will also obtain feedback to improve current hybrid (virtual/in-person) care models from VA providers and Veterans who screened positive, including those who were not detected to have depression. Specific Aims: To improve virtual and in-person services for the VA primary care population during recovery, this proposal will examine how the pandemic disrupted depression care delivery mechanisms, including expanded telehealth, and patient outcomes. Our Specific Aims are: 1) To examine engagement in guideline- concordant care for depression (virtual or in-person) following screening, before and during the pandemic; 2) To compare psychiatric emergency/hospital visits and mortality from suicide between Veterans who screened positive and were detected versus not detected to have depression by clinicians; 3) To understand VA patients' and providers' current perspectives on addressing new depressive episodes using virtual and in-person modalities during the pandemic and eventual recovery. Methodology: Given hypothesized care disruption (lowered care quality) during COVID-19, Aim 1 proposes to extend our preliminary VISN methods nationally to assess the VA population's trajectory from a new positive depression (and suicide-risk) screen to appropriate treatment (i.e., medication, therapy) in FY19-22/23. We will also examine the changing mix of virtual and in-person depression care delivered. Aim 2 will use interrupted time series analyses to explore the extent to which acute care use may be mitigated by clinician detection of depression nationally. We will also compare mortality rates between patients detected and not detected to have depression. Sub-analyses will reveal where (e.g., clinics with low PC-MHI access) and for whom (e.g., minorities) detection does not systematically occur, and downstream negative sequelae, to guide future intervention. Finally, Aim 3 will interview (1) 40 Veterans who were detected and not detected to have depression per Aims 1 & 2 about care-seeking behavior change, digital divide, etc. and (2) 40 VA primary care and PC-MHI providers about staffing shortage, telehealth adoption, etc. across three VAs (GLA, Syracuse, and Durham). In addition to contextualizing disrupted care findings, qualitative data will help isolate best practices on patient-to-provider and provider-to-provider (e.g., handoffs) interactions in hybrid depression care models. Next Steps/Implementation: The COVID-19 pandemic provides the VA with an opportunity to improve upon a system-wide proactive response to depression and suicide, one that is conceptualized to care for the entire Veteran population. This proposed research will provide the basis for testable hypotheses (e.g., acceptable virtual depression treatments in primary care), and clinical recommendations (e.g., satisfactory virtual provider- to-provider handoffs for new patient referrals), to improve virtual and in-person VA depression services.

Background: Despite accessible and effective suicide prevention strategies offered by the Veterans Health Administration (VHA), Veteran suicide remains elevated compared to the general US population, indicating a continued need to identify Veterans at risk for suicide and provide interventions to prevent suicide. Suicide prevention can be enhanced when health care systems integrate dynamic social determinants of health (SDH), such as housing instability, justice involvement, and unemployment.

Significance/Impact: The goal of this HSR&D Veteran Suicide Prevention project is to address prevention activities that occur upstream by examining how services addressing SDH may also prevent suicide among Veterans, key objectives in the VAs National Strategy for Preventing Veteran Suicide 2018-2028.

Innovation: This study will integrate a public health perspective to suicide prevention through a lens of SDH. Rather than focusing specifically on medical intervention, this study will explore based both on a natural experimental design using existing administrative data and on gathering the perspectives of key informants and Veterans how addressing SDH can decrease suicide risk, taking into account the complex needs of Veterans who may be at risk for suicide. Specific Aims: This study aims to determine whether VHA services tailored to address SDH may also have an added benefit of preventing suicide mortality; identify organizational assets and opportunities to improve how SDH-focused services address suicide risk among Veterans; and engage Veterans in identifying ways to integrate suicide prevention into VHA programs that respond to SDH. Methodology: The proposed research is a concurrent mixed methods design. Retrospective quantitative analyses will examine how VHA services tailored to Veterans SDH (i.e., housing instability, justice involvement, unemployment) may protect against suicide mortality and morbidity. A mixed methods environmental scan will include a questionnaire of staff/key informants and qualitative interviews. Qualitative interviews with Veterans with a history of suicide risk will explore how services to address SDH respond to those needs.

Implementation/Next Steps: This project will lead to actionable implementation projects: increased linkages to services for SDH among Veterans with histories of suicidal crisis as well as enhanced training for providers to integrate suicide prevention into services addressing SDH, and vice versa. We have convened an array of VA operations partners Social Work, VHA Homeless and Justice Programs, employment programs, and VA Office of Mental Health and Suicide Prevention to facilitate removing siloes around SDH and suicide prevention in VA, amplifying VAs current infrastructure to bolster suicide prevention.

Background: Emotion regulation (ER) is related to increases in suicidal thoughts and behavior (STB), as well as PTSD. A common mechanism may be autonomic function (via heart-rate variability; HRV), which is altered by chronic stress, supports the success of emotion regulation, and predicts severity of STB. The proposed study will test predictive models of suicide risk among Veterans. Aims: 1) To characterize the predictive relationship between ER and STB. 2) To determine if HRV is a mechanism partially explaining the relationship between ER and STB. 3) To identify the impact that chronicity of PTSD has on the proposed relationship between ER, HRV, and STB.

Methods: This project will utilize a large longitudinal data set (Mind Your Heart Study, N = 746 Veterans recruited from 2008-2010, 94% male, 24-88 years old at baseline). HRV, trauma history (CAPS), STB (PHQ-9, self-reported suicide attempts; SA), and ER (ERQ) was assessed at baseline. Regular follow-up assessment of SI (PHQ-9, SA, SBOR) and PTSD symptoms (PCL) was collected. Data will be modelled using moderated mediation models to assess Aims 1-3. Significance and future plans: This project involves characterizing the mechanistic pathway connecting ER, autonomic function, chronic PTSD, and suicide, as potential targets for risk prediction and intervention. In line with SPRINT funding priorities, it has the potential to engage Veterans not otherwise engaged in care by contributing to the development of a mobile intervention that integrates self-report of emotional states and changes in HRV. Results will be used as proof of concept for a CDA study that will conduct real-time monitoring of changes in HRV and emotional distress in Veterans at high risk for suicide, with an eye towards eventual development of a mobile health intervention that detects increases in distress (via HRV and self-report) and suicidality in order to deliver a just-in-time ER intervention.

Background: Lesbian, gay, bisexual, and transgender (LGBT) individuals have been identified as being at risk for health disparities by the Institute of Medicine. Compared to their heterosexual and non-transgender counterparts, they are especially likely to have higher rates of depression, posttraumatic stress disorder (PTSD), suicide ideation and attempt, alcohol misuse, and smoking. LGBT people are also overrepresented in the Veteran population compared to the general population, especially among women and transgender individuals. Recognizing this vulnerable population as a unique and sizable minority, the VA has made significant efforts to improve care for LGBT Veterans through consultation and staff trainings. Although research on LGBT Veterans has also increased, it has lagged behind, with only a small number of studies on LGBT Veterans to date. The available data suggest that LGBT Veterans experience a high burden of mental health problems and health risk behaviors, though studies have most often failed to examine differences by gender (combining women and men) or sexual identity (combining gay/lesbian and bisexual), and data on some sub-populations (e.g., gay and bisexual men) are extremely limited. Furthermore, few studies have examined the risk and protective factors that may explain these disparities, or LGBT Veterans’ experiences with and preferences for treatment.

Objectives: The objectives of this study are to: 1) identify the extent of sexual orientation and gender identity disparities in mental health problems (depression, PTSD, anxiety, suicide ideation/attempt) and health risk behaviors (alcohol misuse, smoking) among Veterans over time and across geographic regions; 2) examine risk and protective factors associated with these outcomes guided by a conceptual model that is informed by minority stress theory and the self-medication hypothesis; and 3) assess LGBT Veterans’ experiences with and preferences for treatment, including VA utilization, barriers to care, and preferences for tailored interventions.

Methods: This is a prospective cohort study with 1,600 Veterans that will address the three study objectives with 200 individuals in each of the following groups: heterosexual women, lesbian women, bisexual women, heterosexual men, gay men, bisexual men, transgender women, and transgender men. All Veterans will be recruited through online social networking sites and advertisements to online groups. Targeted advertisements will be used to recruit Veterans from sexual orientation and gender identity subgroups. Study assessments will also be conducted online to increase study reach and retention, with measures collected every nine months for 27 months (four assessments). This study targets HSR&D Priorities of Equity and Health Disparities as well as Improving Mental and Behavioral Health Interventions. Findings should greatly improve our knowledge about the extent of existing health disparities, the risk and protective factors associated with them, and treatment preferences of LGBT Veterans. They will also provide critical information for future prevention and intervention efforts for this stigmatized and highly vulnerable group.

Background: Many Veterans experience impairing symptoms of anxiety and seek treatment in primary care, yet anxiety is highly undertreated in this setting. Primary Care-Mental Health Integration (PCMHI), in which mental health clinicians embedded in primary care provide brief treatment, affords an opportunity to address this treatment gap. However, behavioral interventions that are compatible with the brief PCMHI treatment format and able to accommodate a wide range of anxiety presentations are needed. Accordingly, Veterans Anxiety Skills Training (VAST) was designed to be evidence-based, transdiagnostic, feasible for PCMHI, and Veteran-centered. VAST comprises empirically-supported cognitive-behavioral therapy (CBT) techniques adapted into a manualized modular intervention specifically designed for delivery in PCMHI. As VAST is being piloted at a single site with study therapists, the next scientific step is a multi-site randomized controlled trial (RCT) to evaluate its effectiveness using PCMHI providers in routine care.

Significance/Impact: This study addresses Veteran care priorities of mental health and suicide prevention, MISSION Act priorities of increasing access to care and improving patient satisfaction with Veterans Health Administration (VHA) care, and Health Services Research and Development (HSR&D) focus areas of quality, effectiveness, and efficiency as well as implementation science research methods. Improving anxiety treatment in PCMHI will address a major gap in VHA treatment options, given the high prevalence of anxiety in primary care, tendency for patients with anxiety to seek treatment in primary care rather than specialty mental health settings, and absence of Evidence-Based Psychotherapy (EBP) protocols addressing non-trauma related anxiety.

Innovation: Modular (vs. standard) intervention designs offer advantages in efficiency, patient and provider satisfaction, efficacy, effectiveness, implementation, and sustainability. Other innovative aspects include the transdiagnostic approach and examination of fidelity to inform future implementation. Specific Aims: The specific aims are to: (1) Compare patient clinical outcomes for VAST vs. PCMHI usual care between baseline and 16 weeks (post) in a multi-site RCT in which PCMHI providers deliver VAST, and examine whether treatment gains are more likely to be maintained for VAST vs. PCMHI usual care at 28 weeks (follow-up); (2) For participants assigned to receive VAST, explore patient-level predictors of (a) early (8 weeks) and (b) overall (16 weeks) treatment response; and (3) Conduct a mixed-methods process evaluation of VAST implementation to examine rates of, barriers to, and facilitators of achieving and sustaining high-fidelity intervention delivery. Methodology: In this multi-site, hybrid type I effectiveness-implementation RCT, 178 adult Veterans with elevated anxiety symptoms will be recruited from primary care at two VHA sites. PCMHI providers will be randomized to deliver either VAST or usual care (routine PCMHI care, meaning whatever care the provider deems appropriate), and participants will be randomized to condition. VAST (up to six biweekly 30-minute sessions) consists of a standard initial and final session as well as up to 4 CBT skills-based modules. The primary outcome (Overall Anxiety Severity and Impairment Scale) and secondary outcomes (anxiety and depressive symptom severity, functioning, quality of life, suicidality) will be assessed at baseline, 4, 8, 12, 16 (post) and 28 weeks (follow-up). Multi-level modeling will be used to evaluate the hypothesis that patient clinical outcomes will improve more from baseline to 16 weeks for participants receiving VAST compared to PCMHI usual care. Multivariate logistic regression will be used to explore predictors of early (8 weeks) and overall (16 weeks) VAST treatment response. A mixed- methods process evaluation will examine the proportion of PCMHI providers who achieve and sustain high- fidelity VAST delivery as well as barriers to and facilitators of high-fidelity delivery.

Implementation/Next Steps: VAST will be disseminated to VHA PCMHI leadership and providers nationwide using several strategies, and a follow-up hybrid III trial will facilitate formal implementation in VHA PCMHI.

Background: My long-term goal is to become an independent VA health services researcher focused on designing and testing integrated care solutions to improve mental health and substance abuse (MHSA) services access, quality, and outcomes for vulnerable Veteran populations. This CDA-2 will provide me with the necessary mentorship, skills, and experiences to evaluate, modify and implement organizational changes that improve MHSA outcomes for vulnerable Veterans in primary care settings.

Significance/Impact: Veterans who have been homeless have high rates of depression and opioid use disorder and barriers to accessing traditional primary care services. It is important to determine effective models of MHSA services integration at this time when Veterans have more options for care in VA and community settings. VA’s homeless patient aligned care team (H-PACT) program, implemented in over 60 VA facilities, offers a natural laboratory to determine optimal approaches of MHSA services integration to advance Veteran health. My research will impact Veteran health by determining the effectiveness of H-PACT for providing high quality MHSA care and mitigating adverse MHSA outcomes among homeless-experienced Veterans; and by determining the unique and potentially modifiable aspects of H-PACT and other patient aligned care teams (PACTs) that could be scaled to achieve superior MHSA outcomes for homeless-experienced Veterans in specialized and non-specialized PACT settings. This research strongly aligns with VA research priorities of mental health and primary care, and legislative priorities related to addiction recovery and community care.

Innovation: While prior studies suggest H-PACT improves primary care utilization and Veteran experiences with care, there is less research focused on determining what features of H-PACT are successful. We lack data on clinical process measures and outcomes for Veterans empaneled in H-PACTs, information on aspects of MHSA services integration that exists within H-PACTs and traditional PACTs caring for homeless-experienced Veterans, and the barriers and facilitators that contribute to MHSA quality for homeless-experienced Veterans. Specific Aims: My CDA-2 has three primary aims: 1) Compare MHSA services quality of care (e.g., clinical performance measures for depression, opioid use disorder) and outcomes (e.g., psychiatric hospitalization, opioid-related overdose, suicide) for homeless-experienced Veterans empaneled in H-PACTs versus other PACTs in the same facilities; 2) Measure levels and features of MHSA services integration (e.g., coordination with community services, co-location of providers, full integration) for homeless-experienced Veterans in H- PACTs and other PACTs; and 3) Evaluate MHSA service practices and barriers in 4 facilities ranked low and 4 ranked high on measures of MHSA services quality for homeless-experienced Veterans. I will work with my mentors to develop the expertise to study MHSA services quality in primary care settings, and to augment my foundational training with new skills in survey design, qualitative methods and implementation science. Methodology: I aim to 1) use VA administrative data to operationalize MHSA services quality of care based on VA performance measures and established definitions; 2) adapt an organizational survey of H-PACT structures to survey providers from H-PACTs and PACTs about how MHSA services integration is achieved for homeless-experienced Veterans, and; 3) conduct stakeholder interviews in low and high performing facilities to identify barriers to delivering high quality MHSA services for homeless-experienced Veterans. Next Steps/Implementation: Findings will provide information to VA providers, operational partners, and leadership about the effectiveness of the H-PACT initiative, and targets for intervention to bolster lower performing H-PACTs. My pre-implementation research findings and training experiences will inform my future work focused on MHSA outcomes in specialized PACT settings, including an HSR&D effectiveness- implementation study (IIR) application to improve MHSA services quality for homeless Veterans in PACTs.

Background: Opioid prescribing has declined 64% between 2012 and 2020 in the Veterans Administration (VA),1 with high dose prescriptions declining 77%. Although this change likely will prevent prescription-related harm to Veterans, some reports signal adverse events - events that are not well understood - including suicide. Where harm has occurred, it is crucial to know what factors, modifiable and nonmodifiable, played a role. Efforts to examine causal mechanisms for suicide through trials present ethical challenges. Large database assessments may not reveal crucial information that is lacking from medical records. Psychological autopsy research provides a method to collect and analyze discrete, descriptive data concerning the clinical contexts for suicide during opioid transitions, including taper or stoppage.

Significance: The solicitation to which this proposal responds (HX-21-024) prioritizes learning about "benefits and harms of tapering and/or discontinuation." At present, several federal agencies have declared a commitment to averting suicide during opioid taper. But thus far, we lack a deep understanding as to why the suicides occur, which makes preventive and mitigating action difficult to plan. The next logical step in preparing a health system response is in-depth study of the events themselves. Innovation and Impact: Whereas much research has gone toward discerning statistical associations between prescription opioid change and outcomes (including suicide), this project takes a different approach, by applying techniques of psychological autopsy. The pre-requisite challenge to such research is the ability to recruit bereaved survivors who may perceive stigma and who often harbor distrust of health care systems. Our team has invested years in building connections to the community, and allying with suicidologists, so that recruitment becomes possible. Also, by assessing differences between Veteran and non-Veteran suicides, we are positioned to assist VA of its unique assets and liabilities, with the goal of mitigating the latter. Specific Aims: Aim 1. Characterize the patient and clinical context factors associated with suicide among 100 persons (50 Veterans and 50 non-Veterans) who have died by suicide in the context of opioid transition (stoppage or reduction) through survey, structured interview of bereaved family members, and medical record review. Aim 2. Identify factors that may be unique to suicides following opioid transition in Veterans as opposed to non-Veterans, with attention to differences in experience for Veterans in and outside of VA care. Methodology: We will recruit, from the public, family survivors of Veterans and non-Veterans with pain who have died by suicide in the context of an opioid transition. We will work with survivors to solicit medical records from within or outside VA, to review them, and to carry out structured interviews traditional for psychological autopsy. From review of the resulting reports, a multidisciplinary research team (including experts in opioid taper, suicide, addiction, health services research and medical anthropology) will apply the Social-Ecological Framework to identify common personal and contextual factors, to identify aspects of clinical interaction that appear salient to these events, and to identify notable contrasts between those suicides occurring among Veterans as opposed to non-Veterans during opioid transition. Next Steps/Implementation: We intend to present findings quarterly to our patient/family Stakeholder Team and to VA partners (Office of Mental Health and Suicide Prevention, VA National Program Director for Pain Management), so that early and actionable insights are triaged for action. The collation of our research findings and our stakeholder response and feedback allows this project to serve as the first step of the Intervention Mapping process ("Needs Assessment"), which leads in turn to design of preferred outcomes, intervention design and testing.

Background: Posttraumatic stress disorder (PTSD) is a significant risk factor for suicide among Veterans. Evidence-based psychotherapies (EBPs) for PTSD reduce suicide risk, but Veterans at elevated acute risk for suicide, such as those who have engaged in self-directed violence (SDV), rarely receive these treatments. This is largely due to the historical exclusion of high-risk individuals from PTSD treatment trials, which has resulted in a lack of evidence-based guidance about indicated treatments for this population. Without such guidance, clinicians are often reluctant to use EBPs for PTSD with suicidal individuals. A treatment that combines Dialectical Behavior Therapy (DBT), a suicide-focused EBP, with the DBT Prolonged Exposure (DBT PE) protocol for PTSD has been developed for this high-risk population and shows promise in reducing both SDV and PTSD while being feasible, acceptable, and safe to deliver. However, a large-scale randomized controlled trial (RCT) is needed. This study will compare the effectiveness of DBT + DBT PE to the current VHA gold standard of care for this population, Prolonged Exposure therapy augmented with suicide risk management (PE + SRM), while also examining the potential for implementation of both interventions in VHA.

Significance: There is a critical gap in knowledge about how to treat PTSD among individuals at high risk for suicidal behavior. As a result, VA/DoD Clinical Practice Guidelines do not specify indicated treatment strategies for this population. Experts have recommended two approaches to facilitate the safe and effective use of EBPs for PTSD with individuals at elevated acute suicide risk, including combining these treatments with suicide-focused EBPs or augmenting them with suicide risk management strategies. This project will help to fill this critical gap by rigorously evaluating these two approaches among Veterans with SDV. The results will provide important information to inform guidelines about indicated treatments for this high-risk population. Innovativeness: This will be the first large-scale RCT to evaluate treatments for PTSD among Veterans who have engaged in SDV, an HSR&D high priority group. The DBT + DBT PE intervention is the first treatment designed to address both SDV and PTSD, and results will indicate if this novel treatment improves outcomes compared to the current VHA gold standard of care. To facilitate more rapid implementation of these findings into clinical practice, implementation barriers and facilitators for both treatments will also be evaluated. Specific Aims: This study will randomize 200 Veterans with PTSD, recent and repeated SDV, current suicidal ideation, and emotion dysregulation to DBT + DBT PE (intervention) or PE + SRM (control). Aim 1 will test the hypothesis that DBT + DBT PE will be superior to PE + SRM in improving clinical outcomes and engagement in trauma-focused treatment. Exploratory analyses will examine Veteran characteristics that may predict better engagement and outcomes in DBT + DBT PE versus PE + SRM. Aim 2 will examine barriers and facilitators to implementation of both treatments.

Methods: This is a multi-site hybrid type 1 effectiveness-implementation trial. Veterans will be treated in outpatient settings at three VA sites and assessed at 5 points over 18 months. A mixed-methods approach will be used to evaluate barriers and facilitators to implementation, including conducting interviews with 45 key stakeholders (Veterans, providers, and leadership). Primary Outcomes/Endpoints: Primary outcomes will be reductions in SDV episodes at 18-month follow-up and reductions in PTSD severity at post-treatment.

Implementation/Next Steps: This project will provide much-needed information about how to safely and effectively treat PTSD among Veterans at elevated acute risk for suicide. If one or both treatments are found effective, Aim 2 will provide vital information about how to maximize future implementation success. Future implementation activities would be coordinated with our national operational partners.

Background: Seventeen Veterans die by suicide on a daily basis, and Veterans often seek care in Emergency Departments (EDs) prior to a suicide attempt. Lethal means safety (LMS) interventions, which aim to reduce access to common methods of suicide such as firearms or toxic medications, are considered important components of suicide prevention programs and are recommended for Veterans with elevated suicide risk.

Significance/Impact: The Veterans Health Administration (VHA) considers suicide prevention a clinical and research priority. In 2019, VHA began screening all Veterans seeking ED care for elevated suicide risk. The VA’s National Strategy for Preventing Veteran Suicide highlights “efforts to reduce access to lethal means of suicide among Veterans with identified suicide risk.” However, no LMS intervention has been developed to accompany this initiative and prior LMS interventions have not been developed for US Veterans or VHA settings. The proposed work will address this critical gap in VHA suicide prevention efforts by developing and testing a Veteran-centered, ED-based LMS intervention for multiple methods of suicide.

Innovation: Several evidence gaps must be addressed in developing such an intervention. No prior LMS intervention has been shown to be efficacious in promoting medication and firearm safety, and prior interventions have not accounted for the various, person-specific mechanisms by which individuals change behaviors. The proposed intervention will incorporate multiple evidence-informed elements specifically chosen to target different but complimentary behavioral mechanisms highlighted within the Health Belief Model (e.g., self-efficacy) as critical to behavior change. Elements include those that equip staff with evidence-based communication strategies, and provide Veterans with practical, patient-centered support to facilitate LMS behaviors. To ensure that this intervention meets the needs of at-risk ED patients and is sustainable long-term if shown to be efficacious, we will engage Veteran and clinical stakeholders to develop the intervention. Engaging stakeholders in intervention development, an emerging VHA priority, is critical for ensuring feasibility, acceptability, and credibility. As one Veteran remarked during a focus group, “I appreciate you all askin’ us what we’re thinkin’, rather than just sayin’, ya know, here’s what it is and here’s what it’s gonna be.” Specific Aims and Methodology: Aim 1: Identify contextual factors that may inform development of the intervention. I will conduct semi- structured qualitative interviews with up to 30 at-risk Veterans who recently received VHA ED care to identify intrapersonal, interpersonal, and institutional factors that should be considered during intervention refinement and adaptation in Aim 2. Aim 2: Leverage the expertise of a diverse sample of stakeholders to refine intervention elements, adapt them for use among Veterans and within VHA EDs, and develop a final intervention protocol and related materials. Building on prior studies and knowledge gained from Aim 1, I will employ a stakeholder-engaged process to refine, adapt, and finalize the LMS intervention protocol and materials. I will use two evidence-based methods to engage stakeholders and build consensus (Nominal Group Technique, online modified-Delphi process). Aim 3: Pilot the ED-based LMS intervention among 40 Veterans to assess feasibility and acceptability. I will assess feasibility of recruitment, staff fidelity to the intervention, and Veteran engagement, including after ED discharge, and acceptability of the intervention among participants, intervention staff, and ED staff. Next Steps/Implementation: Results from this pilot study will support an IIR application to test the efficacy of this intervention in promoting LMS behaviors among at-risk Veterans. If found to be efficacious, consistent with VHA’s public health approach to suicide prevention and my long-term career goals, my future work will aim to adapt and disseminate the intervention across various VHA (e.g., primary care) and community settings.

Background: Suicide is one of the leading causes of death in the United States and worldwide, with suicide rates among U.S. military veterans doubling (27.7 per 100,000) the rate of civilian levels (14.7 per 100,000). Despite a rise in prevention efforts, rates have continued to increase. Theories of suicide and rehabilitation psychology stress the importance of the person-environment interaction in contributing to one's disability experience. Specifically, research has consistently found that the most frequent precipitant of suicide is a problem with a romantic partner. Conversely, people with better relationship functioning are less likely to have suicidal thoughts. The International Classification of Functioning, Disability and Health (ICF) identifies social engagement and communication as important components of functioning. Prevention of suicide in at-risk veterans is of vital importance and the quality of one's intimate relationship is an understudied intervention target for suicide prevention. This proposal refines and evaluates preliminary efficacy of the first couples-based suicide-specific intervention?Treatment for Relationships and Safety Together (TR&ST). Significance/

Innovation: Suicide prevention is the top clinical priority for VA/DoD. The importance of including family members in Veterans? suicide-related care is a critical component of the National Strategy for Preventing Veteran Suicides 2018-2028 and key finding from VA/DoD patient focus groups conducted for the 2019 VA/DoD Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide. Innovative aspects of this CDA-2 proposal directly address several components of national reports and include: 1) The first couples-based suicide-specific intervention and the first suicide-specific intervention to target interpersonal functioning factors identified by suicide theories and rehabilitation psychology (i.e., effective communication and interpersonal engagement); 2) Veteran-centric choice between home-based telemental health and office-based care in order to increase access; and 3) Improved data analytic quality of Veteran suicidality by examining both Veteran and partner reports of suicide related risk factors (the first suicide- specific treatment study to do this). Methodology: The proposed 5-year study consists of two phases. Phase 1: treatment refinement with 10 couples (N=20) and Phase 2: pilot Randomized Controlled Trial (RCT) of TR&ST compared to VA Standard Suicide Intervention with 60 couples (N=120). The intervention period is 13 weeks and the entire study period is approximately 7 months. Couples in both phases will be quantitatively assessed at baseline, mid-treatment, post-treatment, and 3-months post-treatment (and qualitatively interviewed following each TR&ST module). The primary outcome to be evaluated is change in suicidal ideation severity. Secondary outcomes concern changes in interpersonal functioning. Aims: Aim 1 (Phase 1): Refine TR&ST in a population of Veterans with active suicidal ideation. Aim 2 (Phase 2): Evaluate treatment feasibility and acceptability of TR&ST. Aim 3 (Phase 2): Compare TR&ST vs. VA Standard Suicide Intervention on suicidal ideation severity and interpersonal functioning (i.e., communication, bonding, relationship satisfaction, and belonginess and burdensomeness) over 7 months. Next Steps: This Career Development Award is the first step toward developing a vital program of research within VHA focused on enhancing interpersonal functioning and suicide-related care by involving family members in treatment. If Aims are achieved, future work includes 1) an adequately powered RCT of TR&ST vs. VA Standard Suicide Intervention 2) a more direct evaluation of telehealth for couples-based or family involvement in suicide-specific interventions, and 3) examination of moderators or groups of interest (such as women Veterans).

Background: The first four years after military service separation, while Veterans are reintegrating into civilian life, is the highest risk period for suicide among Veterans. Veterans also face a number of reintegration challenges resuming civilian life roles. Importantly, women and men Veterans may experience this period differently. This study will provide valuable data on the reintegration experiences of Veterans at risk for suicide across six key domains of Veteran reintegration, identify reintegration experiences associated with increased suicide risk, and elucidate gender differences in reintegration experiences and associated suicide risk.

Significance: This study will increase our understanding of suicide risk during Veteran reintegration and will support development of prevention efforts tailored for women Veterans during this period. These data are needed to inform recent executive orders and VA initiatives calling for increased suicide prevention efforts among reintegrating Veterans; findings from this study will identify subgroups of reintegrating Veterans most in need of valuable resources and which reintegration challenges are especially problematic and when enabling VA to develop selective prevention approaches within this important population. Innovation & Impact: This study moves the field beyond cross-sectional studies of suicide risk among Veterans of recent eras and is carefully designed to study gender differences in suicide risk, building on the body of research and theory in suicide prevention and emerging findings of gender differences in suicide risk. Furthermore, this study is innovative in its linking of VA-DoD datasets to identify a national sample of newly separated Veterans at increased risk of suicide who are not necessarily engaged in VA healthcare. Specific aims: The specific aims of this study are to: 1) Model the trajectories of reintegration challenges of at- risk Veterans to identify population subgroups (e.g., stable, deteriorating, improving) and examine gender differences in reintegration experiences, 2) Identify associations between trajectories identified in Aim 1 and suicide-risk-related predisposing factors among women and men, and 3) Identify associations between trajectories identified in Aim 1 and development, or worsening, of suicide risk (suicidal ideation, suicide cognitions, suicide attempts) and any effect measure modification by gender. Methodology: This is a national cohort survey study. We will enroll a cohort of 2,000 Veterans separating from service in the prior six months, identified using the VA-DoD Veteran Identity Repository (VADIR) data. We will oversample for women to enroll a cohort that is approximately half women. We will also oversample for risk indicators available in Department of Defense (DoD) healthcare data available through DaVINCI (i.e., prior mental health inpatient/outpatient visit, emergency department visit, other outpatient visit). After completing the baseline survey, participants will complete 6 additional surveys over the course of a 36 month follow up period. Surveys will include measures that assess functioning in the six core domains of reintegration challenges (mental and physical heath, identity/role negotiation, relationship quality, financial well-being, spirituality) as well as predisposing factors associated with increased risk for suicide and measures assessing suicide risk (suicidal ideation, suicide cognitions, suicide attempts). Main analyses will identify the reintegration trajectories, including any gender differences, examine the suicide-related predisposing factors associated with deteriorating trajectories, and examine suicide risk outcomes associated with reintegration trajectories. Next steps: Data gathered in this study will directly inform the many VA initiatives, legislation, and recent executive orders calling for increased suicide prevention efforts among reintegrating Veterans by providing the necessary data to identify subgroups of Veterans at increased risk of suicide and their respective needs directing valuable resources. The VA Office of Mental Health and Suicide Prevention and the VA Office of Social work are strong partners in these efforts and will support dissemination and implementation of findings.

Background: Veteran suicide prevention remains the top clinical priority for the Veterans Health Administration (VHA). To mitigate Veteran suicide risk, VHA has national guidelines recommending an enhanced care package after self-directed violence (SDV) such as creating a suicide safety plan or increasing the frequency of outpatient mental health visits. Adherence to each given care component is considered a marker of care quality for suicide risk (henceforth referred to as suicide-related care quality). Recent research utilizing national VHA data suggests these care components may not be provided equitably to all Veterans. As research shows that Black, Indigenous, and People of Color (BIPOC) Veterans experience poorer mental health care quality than white Veterans, it is possible that similar issues may impact their suicide-related care quality. However, no research to date has examined the quality of suicide-related care among BIPOC Veterans. Thus, further evaluation of suicide-related care quality is needed to ensure equitable, effective care for BIPOC Veterans with SDV. The current proposal seeks to evaluate components of suicide-related care quality among BIPOC Veterans using a concurrent, mixed-methods triangulation approach to inform future intervention development.

Significance: The proposed project directly addresses VHA's top clinical priority, suicide prevention. In addition, this proposal aligns with VA HSR&D's high priority foci of suicide prevention and health equity as well as VHA National Strategic Plan Objectives 2.1 and 2.3 which focus on ensuring Veterans receive equitable, comprehensive suicide prevention services to support their recovery. VHA Office of Health Equity and VHA Office of Mental Health and Suicide Prevention also highlight in their strategic plans the need for supporting equitable, suicide-related care for all Veterans. Innovation and Impact: The proposed project is the first evaluation of suicide-related care quality among BIPOC Veterans with SDV. In addition, no research to date has determined areas to improve suicide-related care quality for BIPOC Veterans. Use of national VHA- and non-VHA administrative data triangulated with BIPOC Veteran and mental health clinician qualitative data will result in a richer conceptualization of current factors impacting suicide-related care and inform future strategies for enhancing care. Specific Aims: Aim 1) Evaluate suicide-related care quality among BIPOC Veterans; Aim 2) Conduct qualitative interviews with BIPOC Veterans and VA clinicians to better understand factors impacting suicide-related care quality for BIPOC Veterans; Aim 3) Explore associations between health care systems-level factors and suicide- related care quality indicators for BIPOC Veterans; Exploratory Aim) Explore the relationship between suicide- related care quality among BIPOC Veterans and suicide outcomes. Methodology: Aim 1 will identify BIPOC Veterans with SDV (FY18-FY22) utilizing VHA databases. Data from the VHA Corporate Data Warehouse for suicide-related care quality outcomes as well as sociodemographic and clinical variables will be linked. Data will be analyzed using generalized estimating equations. Aim 2 will involve interviews with at least 40 BIPOC Veterans and at least 40 VHA mental health clinicians about their beliefs and experiences with suicide-related care which will be analyzed using thematic analysis. Aim 3 will link data from Aim 1 to health care systems factors at the station level. For the Exploratory Aim will link data from mortality data sources to explore associations with mortality outcomes. Next Steps/ Implementation: The proposed project will increase our understanding of factors impacting suicide- related care quality among BIPOC Veterans. Findings from this project will inform future proposals focused on intervention development to enhance suicide-related care quality among BIPOC Veterans.

Background: Veteran suicide rates are 1.5 times higher than the general population rates and are especially high following discharge from an inpatient mental health unit when up to a third of patients do not receive timely outpatient follow-up care. Technology-based interventions are a scalable approach to provide additional support to patients during these high-risk transitions. The Virtual Hope Box (VHB), a mobile phone application (app) developed by the Department of Defense (DoD) and VA, allows patients to access reasons for living and coping tools regardless of their location. VHB was effective for improving coping self-efficacy in a small randomized controlled trial; however, no studies have been adequately powered to examine VHB's effectiveness for suicide attempts. Additionally, knowledge and use of the app is low according to a preliminary study of mental health inpatients, calling for new strategies to facilitate greater use and impact of the VHB app.

Significance: The suicide rate among Veterans rose 35.9% from 2001 to 2019, leading to VA to make suicide prevention a top clinical priority. We developed an intervention, which includes the VHB app and its enhanced facilitation (VHB-EF), with the aim of reducing Veteran suicide attempts. Developing and implementing effective strategies to reduce suicide attempts post-hospitalization is also a research priority within this RFA. Innovation/Impact: We developed VHB-EF to provide awareness, active engagement, and support of VHB with the aim of reducing suicide attempts post-hospitalization. This study will be the first to test the effectiveness of VHB-EF on suicide attempts and may improve safety after discharge. It will examine potential intervention mechanisms, according to self-efficacy theory and the theory of planned behavior, while also considering ultimate implementation and scalability of the VHB-EF through provider and Veteran feedback. Specific Aims: Aim 1: Determine the effectiveness of VHB-EF for reducing suicide attempts. Aim 2: Examine the intervention mechanisms by measuring the effects of VHB-EF on 1) reasons for living, and 2) self-efficacy to (a) cope and (b) refrain from suicide attempts. Exploratory Sub-aim 2: Examine whether higher reasons for living and self-efficacy partially mediate the effect of VHB-EF on suicide attempts over 6 months. Aim 3: Assess the determinants (barriers and facilitators) of VHB-EF adoption to inform future implementation and sustainability of VHB-EF across the VA. Methodology: A randomized effectiveness-implementation Hybrid Type I trial will be conducted at two VHA inpatient mental health units. We will randomize 928 Veterans hospitalized after a suicidal crisis to either VHB- EF or Enhanced Usual Care (EUC). The VHB-EF includes a single session on the unit that educates Veterans on app purpose for suicide prevention, loads the app on their personal phone, provides practice of each app component, and discusses strategies to enhance app usage after hospital discharge. It also includes a remote- delivery phase which includes 2 phone calls after discharge to monitor risk, review/revise VHB content, and support app use and outpatient treatment engagement. The EUC arm consists of reviewing a community resources list. We will assess how VHB-EF (vs. EUC) impacts suicide attempts, as well as potential mediators, across follow-up assessments (6 weeks and 3- and 6- months post-randomization). Qualitative interviews with providers and Veterans will focus on barriers and facilitators of adoption. Next Steps/Implementation: The VHB is already accessible in VA, but active intervention is needed to engage high-risk suicidal Veterans, and additional effectiveness evidence is needed to support its incorporation into treatment guidelines for suicide prevention. Through qualitative interviews we will examine the determinants (barriers and facilitators) of VHB-EF adoption to inform future implementation and sustainability of this approach across the VA. Broader implementation of the intervention will be coordinated with Office of Mental Health and Suicide Prevention who supports the proposal.

BACKGROUND: Veterans are at elevated and increasing risk for suicide, relative to civilians. In particular, female Veterans are nearly twice as likely to die by suicide, compared to female civilians. In addition, 70% of Veterans who died by suicide did not use any Veterans Health Administration (VHA) care in the year before death. Consequently, female and non-VHA Veterans have been identified as two target populations in the VA National Strategy for Veteran Suicide Prevention. Yet most suicide prevention research has focused on VHA users and male Veterans. Knowledge is thus limited regarding whether VHA and non-VHA users differ with respect to who dies by suicide, precipitating circumstances of death, and regarding gender differences within these domains. Moreover, while mental health (MH) care offers an important opportunity to recognize and intervene upon suicide risk, knowledge is limited regarding barriers to accessing MH or suicide-specific care, particularly in relation to whether these differ by gender or VHA use. These gaps preclude determining the most effective and patient-centered means of preventing suicide among both female and male Veterans, particularly those who not using VHA care. SIGNIFICANCE/IMPACT: The present study has strong implications for understanding and preventing suicide among non-VHA users and female Veterans, both of whom have been vastly understudied. This is particularly crucial considering: (1) the 2016 Female Veteran Suicide Prevention Act, which directs VA to determine the most satisfactory and effective MH and suicide prevention programing for female Veterans; and (2) the 2019 Executive Order on a National Roadmap to Empower Veterans and End Suicide, which directs VA to work side-by-side with communities to reduce suicide among all Veterans, not only those using VHA services. This study will increase knowledge of female and male Veterans who died by suicide, including circumstances surrounding death, and the extent to which suicide decedents accessed MH care prior to death. Such knowledge can be garnered to tailor prevention efforts across Veteran groups. Moreover, by engaging with living Veterans, this study will improve understanding of Veterans' experiences and willingness to seek MH care in general and when suicidal, while also informing the extent to which their experiences, barriers, and preferences differ by gender and VHA use. This knowledge is timely and critical as VA seeks to engage more Veterans in care. INNOVATION: This study will be the first to identify factors differentiating VHA and non- VHA suicide decedents and to explore female and male Veterans' experiences and preferences for seeking help when suicidal. This study is also innovative in conceptualizing non-VHA users as comprising Veterans who were lost-to-care and who never used any VHA care. SPECIFIC AIMS: This study uses mixed-methods to compare three groups of Veterans (VHA users, never users, and lost-to-care) across three aims: (1) Identify factors that differentiate Veteran suicide decedents (e.g., circumstances of death, MH care use); (2) Examine differences in willingness to seek MH care, barriers to using MH care, and MH care experiences; and (3) Describe and compare Veterans' experiences, preferences, and barriers to help-seeking when suicidal. Gender differences will be examined across aims. METHODOLOGY: For Aim 1, probabilistic linkage of data from national sources will be combined for Veteran suicide decedents to evaluate circumstances of death (e.g., interpersonal and socioeconomic stressors, MH problems), as well as VHA MH care use (for VHA and lost-to-care decedents). For Aim 2, Veterans will be surveyed about their willingness to seek MH care, barriers to doing so, and MH care experiences. For Aim 3, qualitative interviews will explore Veterans' experiences, barriers, and preferences for seeking help when suicidal. Female Veterans will be oversampled. IMPLEMENTATION/NEXT STEPS: Intended impacts include greatly enhancing knowledge and facilitating new opportunities for implementing patient- centered, gender-sensitive suicide prevention strategies for all Veterans. Findings will be consolidated, and key stakeholder input obtained to propose actionable clinical and policy changes.

Background: Veterans disproportionately account for to 22% of all known suicides in the US. Screening for suicide risk at the first contact with an organization is a best practice in the national Zero Suicide framework and vital to enhancing access to appropriate care. Transition Care Management (TCM) programs are positioned to screen post-9/11 Veterans at the critical moment of enrollment in healthcare. Unfortunately, many Veterans who present for the first time in VHA with recent suicidal thoughts do not receive same day suicide risk evaluation (SRE), partly due to cumbersome screening processes. eScreening is a web-based Gold Standard Promising Practice electronic screening system with real-time scoring and integration into CPRS/VistA. Our eScreening effectiveness pilot in 1,372 post-9/11 Veterans and our 2-site multicomponent implementation strategy (MCIS) pilot showed increase speed and rate of SRE and sustainment of eScreening in two pilot sites. More research is warranted to test both.

Significance/Impact: This project responds to HSR&D Priority Areas of: Suicide prevention, Increasing the real-world impact of research, and Implementation science. Our data will inform best practices in suicide prevention through early identification. This project will also allow for real-world integration of research into practice and inform implementation efforts for technology.

Innovation: eScreening is a unique program developed with feedback from Veterans. To our knowledge, this is the first study to integrate VHA developed mobile patient-report screening technology to improve screening in TCM programs. It is also the first to examine the impact of electronic screening on rates of suicide risk evaluation and referral to care. Specific Aims: Aim 1. Evaluate the effectiveness of eScreening, compared to paper and verbal screening, on rate and speed of screening completion (suicide screening & evaluation, PTSD, depression, alcohol) and referral to mental health care in 8 TCM programs, guided by the RE-AIM outcomes of PRISM. Aim 2: Evaluate the feasibility, acceptability, and potential impact of the MCIS, guided by the RE-AIM outcomes of PRISM, adoption, implementation, and maintenance using mixed methods. We will also document and calculate replication costs across sites. Aim 3. Describe and compare high and low eScreening reach sites guided by contextual constructs of PRISM using qualitative comparative analysis to explore factors influencing the reach of eScreening and the use of the eScreening MCIS. Methodology: We propose an 8 site 4-year, stepped-wedge, mixed-method, Hybrid Type 2, pragmatic trial to compare eScreening to screening as usual while evaluating potential impact of the MCIS in TMC programs. Aim 1 outcomes will be collected via deidentified chart pull at the start and end of the pre-implementation phase, the 9-month intervention period, and 9-months post intervention. Aim 2 outcomes will be collected quantitatively from TCM staff questionnaires and qualitatively from interviews. Aim 3 data will be collected at the same intervals as Aim 2. Next Steps/Implementation: We will use the findings of this research to inform suicide prevention early identification best practices and enterprise scale-up of eScreening with our VACO partners.

Background: Veterans' suicide risk is highest during the first year after military service separation. This heightened suicide risk has been associated with difficulties reintegrating into civilian life. Deficiencies in role functioning (knowing who you are and where you are heading in life) is one of the most commonly reported challenges during reintegration. Role functioning is critical for optimal functioning in adult life roles (e.g., employment) and it is predictive of suicidal ideation and attempts. However, there are no evidence-based interventions that address role functioning to reduce suicide risk and improve functioning in adult life roles.

Significance: The importance of reaching Veterans proximal to service separation outside of traditional clinic settings is clear; Veterans' risk for suicide is highest within the first year of service separation and Veterans are not well-connected to VA care or other services during this time period. Health coaching is a non-clinical health behavior change modality that is designed to improve role functioning and can be delivered virtually (via telephone/video). Although health coaching has been embraced by the Veterans Health Administration (VHA), no rigorous, fully powered trials have examined the effectiveness of health coaching. Virtually-delivered health coaching may be an easily scalable, low-cost approach to reach reintegrating Veterans outside of clinic settings to reduce suicide risk and improve functioning in adult life roles.

Innovation: No studies have examined the use of health coaching among reintegrating Veterans outside of the clinic setting. This study's strategic use of virtually-delivered health coaching builds on VHA's investment in this non-clinical modality that has the potential to reduce suicide risk during a high-risk transition period. Specific Aims: This pilot study will 1) Examine the feasibility of study procedures and acceptability of the health coaching intervention among reintegrating Veterans; 2) Evaluate measures of mediators and outcomes for suitability in a future confirmatory efficacy trial; and 3) Determine barriers and facilitators of implementation of health coaching among reintegrating Veterans. Methodology: We will enroll a national sample of 94 Veterans within three months of military service separation and follow them for 9 months, capturing their first year of separation. Participants will be randomized to health coaching + enhanced usual care (EUC) or EUC only. The intervention group will receive up to 12 health coaching sessions over the phone or via video (per participant preference). All participants will receive a booklet about VA benefits and services, organized by functional domains, as an enhancement to "usual care." Participants will complete self-report assessments at baseline, mid-intervention (month 2), post- intervention (month 4), and follow-up (month 9). Approximately 30 participants will complete qualitative interviews on their experiences with health coaching and intervention coaches will complete exit interviews on their experiences delivering coaching. VHA administrative data will be used to ascertain VHA care utilization. We will use study log data, a satisfaction measure, and qualitative interviews to examine feasibility of the study methods and acceptability of the intervention, including potential harms. Evaluation of measures for inclusion in a future efficacy trial will involve characterizing typical variation, descriptive analyses of within-person change across time, and adjusted estimates of treatment effect sizes with 95% confidence intervals. To inform barriers and facilitators to implementing virtually-delivered health coaching we will analyze Veteran qualitative interviews and coach exit interviews using a primarily descriptive thematic analysis approach. Next steps: Data gathered in this study will inform design of a subsequent efficacy trial of virtually-delivered health coaching among reintegrating Veterans and future implementation strategies. This line of research will inform the strategic use of virtually-delivered health coaching as a population-based rehabilitation approach to reduce suicide risk and improve functioning in life roles among reintegrating Veterans.

Curating an ever-growing library of community level environmental and social determinants of health variables - Support SPP and NIH Cancer grant. Develop a well-functioning partnership with GeoBISL to host ORNL currated geospatial data Include a new geospatical dta domain in CDW for enterprise use, ETA Summer 2022. Need ORNL support to enable on-going updates

Death by suicide has been steadily increasing in the last 20 years, and this risk is elevated among veterans, particularly those with traumatic brain injury and psychiatric diagnoses. However, in the last 50 years, improvements in identifying those at greatest risk for suicide, typically via self-report, have been limited. Therefore, we propose that complementary and objective neurobiological markers of suicidal thoughts and behaviors (STBs) can improve the identification of those at greatest risk. Preliminary brain markers related to STBs have been identified in the cognitive control network (CCN), limbic network (LN), and the default mode network (DMN). However, reliable and predictive brain markers of STBs remain elusive as there are several methodological limitations in the previous literature. This study will address these limitations and investigate neural markers of STBs using two different neuroimaging methods: resting-state fMRI and brain activity during the suicide Implicit Association Task (s-IAT). Resting-state provides a stable and reliable measure of intrinsic brain connectivity, whereas the behavior on the s-IAT (known as the d-score) measures the strength of a participant's implicit association between self and death. The d-score on the s-IAT is a better predictor of future STBs than self-report, but little is known about neural activity related to the s-IAT. DESIGN AND METHODS. This application utilizes a close collaboration with the Translational Research Center for TBI and Stress Disorders (TRACTS), which has a comprehensive psychiatric and neuroimaging database of over 800 post-9/11. This dataset provides the unique opportunity to compare STB groups with control groups matched on psychiatric diagnoses, like depression and PTSD, that are differentiable only by the absence of STBs (psychiatric controls; PCs). Using this existing dataset, resting-state fMRI will be used to identify brain markers related to both a history of suicide attempt (SA) and current suicidal ideation (SI). Next, we will determine if these brain markers predict future STBs using state-of-the-art machine learning techniques. Lastly, an additional 100 veterans will complete the s-IAT with concurrent fMRI as part of their participation in TRACTS. This will allow us to investigate the feasibility of detecting neural makers related to implicit associations between self and death (d-score). Aim 1: Identify neural signatures of previous suicide attempt and current suicidal ideation (n = 800, ~5% with history of suicide attempt, ~10% with suicidal ideation). Hypothesis 1. We will identify neural markers in the LN, CCN, and DMN, that differentiate those with STBs from PCs. Aim 2: Determine if the STB neural markers identified in Aim 1 predict future STBs 1-2 years later at a follow- up assessment (n=400; ~5% attempt suicide within the next 1-2 years and ~10% reporting current SI at follow- up). Hypothesis 2: Models using the SA and SI neural markers identified in Aim 1 will predict which individuals report STBs at a follow-up assessment with acceptable diagnostic accuracy (sensitivity and specificity). Aim 3: Acquire preliminary fMRI data on the suicide Implicit Association Task (s-IAT) to determine the feasibility of measuring brain activation related to self-death associations (d-score). Hypothesis 3: We will discover preliminary neural markers of this STB-related cognitive process, which will partially overlap with resting-state markers of STBs, and also include brain regions associated with self-referential processing. Training Aims. This CDA will provide training in 1.) The assessment, prevention, and neurobiology of suicide, 2.) Advanced statistical and machine learning techniques, 3.) Task-based fMRI, and 4.) Preparation to submit a competitive CDA-II. IMPACT. This project will provide a foundation for a future CDA-II proposal investigating these neural markers of STBs in high-risk populations and as targets for brain stimulation with the long-term goal of using these neural markers to develop new treatments and improve suicide prevention.

Deep-learning and other modeling approaches to understanding suicide risk and identifying at risk individuals for intervention. Examining free-text predictors of suicide death among patients not identified as HRF at the time of the event. Will control for REACHVET predictors. Developing methods for deep-learning based NLP algorithm development, and/or augmentation of annotation-based development methods. Use of facility variation in clinical practice to evaluate effects of practice on clinical outcomes. Initial focus is on psychotropic prescribing practices.

Despite substantial efforts to curb Veteran suicide, Veterans continue to die by suicide at rates that far exceed their civilian peers. To date, substantial resources have been invested into understanding and treating underlying risk factors and precipitants of Veteran suicide. However, criminal justice involvement remains an under-examined and under-assessed risk factor for Veteran suicide. Accumulating research suggests justice-involved Veterans are a high-risk, high- need population, particularly within the Veterans Health Administration. For example, 11% of Veteran suicides are precipitated by legal troubles; 79% of Veterans receiving VA supportive housing assistance have a history of one or more arrests; and 58% of Veterans receiving outpatient VHA substance use treatment have a history of three or more arrests. Risk for suicide among justice-involved Veterans is particularly elevated among those with co-occurring difficulties, such as mental health concerns and/or housing instability. Adequately addressing Veteran suicide both for justice-involved Veterans and the broader Veteran population therefore likely requires interventions to address the legal and co-occurring difficulties of at-risk Veterans. Dialectical Behavior Therapy for Justice-Involved Veterans (DBT-J) is distinctively designed to address these range of needs faced by justice-involved Veterans, including heightened suicide risk, antisocial behaviors, mental health and substance use concerns, community-based structural barriers, and case management difficulties. Combining elements of three prominent, evidence-based models, DBT-J provides 16 weeks of group psychotherapy, case management services, and measurement-based care to Veterans with ongoing or recent criminal justice involvement. Data from two prior clinical trials completed by the proposed study's Principal Investigator attest to the feasibility and acceptability of DBT-J within VHA behavioral health settings. Although preliminary, data also suggest participation in DBT-J may yield meaningful reductions in risk for future criminal behavior and resolution of high-priority case management needs. Continued research, however, is needed to further investigate the program's efficacy. Toward these aims, the proposed Phase III clinical trial will: 1) Primary Aims 1-2: Assess the superiority of DBT-J over supportive group therapy in decreasing risk of future criminal behavior and increasing psychosocial functioning. 2) Secondary Aim: Assess the superiority of DBT-J over supportive group therapy in improving secondary treatment targets (i.e., suicidal ideation, criminogenic thinking, psychological distress, substance use, case management needs, quality of life, resilience, suicide-related behavior, and criminal recidivism). 3) Exploratory Aims 1-2: Assess for differential efficacy of DBT-J across high-priority JIV subgroups (i.e., violent versus nonviolent most recent offense type, presence/absence of a substance use disorder, and presence/absence of a severe mental illness); assess long-term impact of DBT-J participation (versus participation in supportive group therapy) on primary and secondary treatment targets.

Develop a firearms safety intervention that involves a concerned significant other. Pilot the intervention on 10 dyads.

Dr. Amy Byers' research is predominately focused on suicide prevention in older Veterans. This work is highly relevant to and has very high impact on Veterans and VA healthcare. Veterans 50 years and older have the highest number of lives lost to suicide and make up the majority (> 70%) of the Veteran population. Older adults and, in particular, older Veterans accumulate a significant amount of life experiences, including suffering multiple comorbidities, losses, and traumas, that impact their mental and physical well-being. Even further adding to the complexity, mental health care often occurs in non-mental health settings under the influence of personal and society notions and stigmas about mental illness and about aging. Dr. Byers' Lab is uniquely positioned to conduct research at this level of complexity. Dr. Byers has developed a deep, clinically relevant understanding of the nature of mental health in late life, its course, treatment and impact. Her research covers multiple sub-areas of late-life mental health, i.e., late-life suicide, late-life posttraumatic stress disorder, mental health services use with age, geriatric depression, and gerontological biostatistics. In particular, understanding suicide-related outcomes in older adults/Veterans requires substantially different conceptual and methodologic considerations, which Dr. Byers and her team are uniquely qualified to undertake. There are 4 over-arching research areas and Aims that Dr. Byers will actively pursue during the proposed Research Career Scientist Award period: 1) To characterize and identify patterns of health services use and diagnostic profiles at a national level among older adults/Veterans who have experienced late-life suicide or mental health disorders; 2) To identify predictors of late-life suicide; 3) To advance late-life suicide and mental health research in prominent health disparity and vulnerable groups; and 4) To advance suicide and neuropsychiatric research in Veterans incarcerated and returning to community in later life. In summary, the first 3 Aims are supported by an on-going VA CSR&D Merit Award (I01 CX001119; PI: Byers). Aim 2 and 3 are further supported by a Genius Award (PI: Byes) from the UCSF Older Americans Independence Center (NIA-funded Pepper Center). Aim 4 is supported by a NIMH Multi-PI R01 grant in collaboration with Dr. Lisa Barry from University of Connecticut (MH117604; Multi-PI: Byers/Barry). Additionally, Dr. Byers and Dr. Barry were recently awarded a NIMH/NIA Supplement to the parent grant to determine the burden of Alzheimer's disease and related diseases in older adults/Veterans with a recent history of incarceration. There are many seminal contributions by Dr. Byers' Lab in terms of highly cited papers in high impact journals in support of these on-going activities. To name a few, she was the first to determine the high occurrence of late-life mood and anxiety disorders at a national level, first to determine and characterize nationally that the majority (~70%) of older adults with mood or anxiety disorders did not use mental health services, first to identify comorbidity profiles in Veterans 65 years and older who were last seen in primary care prior to a suicide attempt, first to determine in a national cohort that risk of suicide attempt was increased in Veterans recently diagnosed with mild cognitive impairment or dementia (in press at JAMA Psychiatry), first to provide evidence that hormone therapy is an indicator of suicide risk among midlife to older women Veterans (even independent of psychoactive drugs), and seminal work showing a nearly 5-fold greater risk of a subsequent suicide attempt in older Veterans transitioning from prison to community. Dr. Byers is investigating other unique patterns of potential markers and predictors of late-life suicide risk (supported by I01 CX001119), including "high-risk" medication use (i.e., benzodiazepines, sedative-hypnotics, opioids, antidepressants, antiepileptics, and antipsychotics) and polypharmacy patterns, and conducting seminal research to determine specific medications causally linked to risk of suicide in older Veterans. Moreover, she is actively pursuing more research on vulnerable groups (female, minority, homeless, and PTSD), including Veterans transitioning from incarceration to community in later life.

Evaluation of a clinical pilot of CBT-SP via Telehealth in VISNs 19 and 10 for feasibility and acceptability. Lessons learned to be provided to OMHSP (SPP) to inform the national rollout of CBT-SP as an EBP for Suicide Prevention 2.0.

Even the strongest of individual risk factors are poor predictors of suicide attempts. Many risk factors rely on subjective or self- reported measures and underreporting contributes to poor prediction accuracy. In the midst of the ongoing Veteran suicide crisis, we clearly need new, objective predictors of risk that can be implemented across the VA system. Previous findings indicate that behavioral and neuroimaging correlates of decision- making and cognitive control are promising, objective markers of suicidal risk. Though intriguing, these findings are from research conducted primarily in depressed civilians. It is unknown if these potential markers of suicide risk will generalize to a transdiagnostic sample of Veterans. The primary research objective of this CDA- 2 is to evaluate whether structural neuroimaging, and functional neuroimaging during decision- making and cognitive control tasks can be used to identify brain- behavior correlates of suicidal thoughts and behaviors in Veterans. Suicidal thoughts and behaviors are associated with short- sighted, maladaptive, decision- making that is accompanied by differences in striatal- prefrontal reward circuitry. However, studies that have compared decision- making task performance between individuals who have made more organized, lethal attempts at self- harm vs. those making less serious attempts have identified differences in their behavior that may supply more nuanced information about suicidal severity. Interestingly, the decision- making of serious attempters is actually less impulsive. In fact, decision making in serious attempters is less impulsive even relative to healthy controls. This implies that a greater capacity for cognitive control may facilitate, rather than protect against, harm in suicidal individuals. These potential objective markers of suicidal thoughts and behaviors and suicidal risk severity are promising and demand further evaluation. The proposed behavioral and neuroimaging methodologies (diffusion imaging, morphometry analyses, univariate and functional connectivity neuroimaging) included in this proposal have been successfully applied by the candidate, a cognitive neuroscientist, in previous published work. The candidate's exploratory research objective is to apply machine learning algorithms to a blended dataset of participants? electronic health data and neurocognitive markers in a preliminary predictive modeling project. This exploratory objective will provide foundational data for future Merit- funded work focused on the development of clinically implementable suicide risk prediction tools. Though the proposed neurocognitive research has the potential to improve the effectiveness of suicide screening and treatment, the candidate acknowledges that all too often, insights from neuroscience fail to improve clinical care because few neuroscientists have the clinical perspective needed to translate mechanistic knowledge into clinical innovations. The protected time funded by this CDA award will allow the candidate to participate in activities imparting a unique combination of skills and perspectives that will allow the candidate to bridge basic and clinical science in the service of reducing Veteran suicide. The CDA training plan builds competencies in three areas: 1) methodologies and practical skills for suicide research, 2) psychiatric assessment and clinical perspective, and 3) training in bioinformatics and machine learning methodologies. The candidate is well- established within the VA system holding a Health Science Specialist position since 2015. The candidate's mentorship team is comprised primarily of VA clinician- scientists actively working with suicidal or high- risk populations and are well- qualified to mentor the candidate toward the career goal of becoming a leader in translational Veteran suicide research.

Impaired executive function, such as impaired decision making and impulsivity, has been identified as an important contributor to the transition from suicidal ideation to suicide attempt. To address the epidemic of Veteran suicide in the United States, we propose to test the feasibility, acceptability, and preliminary effectiveness of a five day transcranial direct current stimulation (tDCS) augmented executive functioning training intervention. This intervention will be delivered to inpatients who have been admitted to the 1K psychiatric unit and deemed to be at hightened suicide risk. The ultimate goal is to reduce future suicide events (ideation, attempts, deaths) and improve quality of life (e.g. social relationships, health resource utilization). We propose to test feasibility and acceptability of a five day intervention of ten sessions of tDCS augmented executive function training in a high suicide risk population: Veterans admitted to the 1K psychiatric unit and deemed to be at hightened suicide risk. Inpatients have the highest risk of suicide attempts within the initial weeks following discharge with 50% occurring within 12 weeks of discharge. This suggests that the time prior to hospital discharge could be a critical intervention period. Thirty-eight Veteran inpatients in the 1K Psychiatric unit will be recruited. The five day intervention will be delivered during inpatient stay, prior to discharge. We will collect measures representing multiple domains related to suicidal ideation and behavior, including executive function cognitive performance, and self-report measures of impulsivity, suicidal ideation and behavior, and help seeking. These measures will also be collected at 1 month and 2 months following discharge. Additionally, we will collect longitudinal and daily real-time data on help-seeking, suicide risk, and related factors in the month after discharge using Ecological Momentary Assessment (EMA). Reducing Veteran suicide has been the top clinical priority of the VA for the last few years. However, the total number of suicides among Veterans has continued to increase. There is a critical need for targeted treatments to reduce the risk of suicide in Veterans. Previous research has shown that the transition from inpatient to outpatient care, including the four weeks after discharge from inpatient care is one of the highest risk periods. The low cost, simplicity, and safety of this intervention makes it easy to deliver and scale to clinical settings. If this pilot trial is successful, it would set the stage for a larger trial to test the effectiveness of this intervention for reducing suicide events in a high suicide risk population, and help guide future rehabilitative and treatment approaches.

In 2019, 44.0% of Veterans accessing homeless services did not receive a screening (i.e., Columbia Suicide Severity Rating Scale Screener [C-SSRS]) or evaluation (Comprehensive Suicide Risk Evaluation [CSRE]) for suicide risk in the year prior to or following their intake. Such screening and/or evaluation could have occurred across many clinical settings; thereby highlighting challenges identifying and enhancing suicide prevention efforts for homeless Veterans accessing Veterans Health Administration (VHA) care. Moreover, homeless Veterans often rely on care received in VHA emergency settings (e.g., emergency department [ED]/urgent care center [UCC]) to manage medical and psychiatric conditions. As such, ED/UCC settings are critical points of contact for identifying homeless Veterans at risk for suicide and ensuring they receive optimal, empirically-supported suicide prevention treatment (e.g., Safety Planning) and post-discharge outreach to connect them to outpatient care. Nonetheless, to date, projects have not focused on enhancing suicide risk screening and evaluation (i.e., VA Suicide Risk Identification Strategy [Risk ID]), intervention, or outreach (i.e., Suicide Prevention in the Emergency Department [SPED]) among homeless Veterans accessing ED/UCC services. This project seeks to enhance homeless Veteran suicide prevention and clinical care by: 1) Evaluating receipt of suicide risk screening and evaluation (Risk ID), as well as Safety Planning and post-discharge outreach (SPED) among homeless Veterans presenting to VHA ED/UCC settings; 2) Identifying barriers and facilitators to implementing Risk ID and SPED among homeless Veterans accessing VHA ED/UCC services; and 3) Developing suicide prevention resources including trainings and web-based materials, aimed at addressing barriers to to homeless Veterans receiving VHA suicide prevention mandated services (Risk ID/SPED) in ED/UCC settings.

In addition to their metabolic and cardiovascular protective effects, statins reproducibly engage multiple pathophysiological factors implicated in suicidal behavior - neuroinflammation, increased oxidative stress, excitotoxicity, and endothelial dysfunction. Add-on statins have been also reported to improve therapeutic control in physical and mental health. The Veterans' persistent higher rates of suicide have remained unabated challenges and, and thus, demanding new ways of understanding and engaging in preventative efforts. The long-term objective of our group is to uncovering new modifiable targets, novel and repurposed treatments in suicide prevention, and identifying individuals at risk who are likely to most benefit from specific interventions. Macro-epidemiological approaches using electronic medical records in suicide research are irreplaceable for their capability to account for multiple interactive risk factors, moderators and confounders, and potential for immediate impact. The primary aims of the proposed research project are to: 1) Estimate potentiating interactions between traumatic brain injury (TBI), a very common condition in US Veterans, and inflammation-mediated medical conditions (IMCs: allergies, infection, and autoimmune conditions), in predicting suicide in US Veterans. Our preliminary data support hypothesizing synergistic interactions. 2) Estimate the suicide protective effect of sustained vs. unsustained statin treatment 3) Identify demographic and clinical Veteran characteristics and pharmacological statin features (dose, lipophilia, potency, duration) conducive to stronger attenuating effects of statins on suicidal behavior. We will test these hypotheses on a Veterans Health Administration (VHA) retrospective cohort (individuals with clinical encounters in VA Medical Centers nationwide beginning in 2004 and followed for 13 years) including 5,446,318 Veterans with 28,749 suicides. The Cox proportional hazard model will be applied to evaluate the interactions between TBI immune mediated conditions , with Relative Excess Risk due to Interaction (RERI), the Attributable Proportion (AP) due to interaction, and the Synergy Index (SI) to test synergism on an additive scale (Aim 1). A Cox proportional hazard model will also be applied to testing risk attenuation with statins, with propensity scoring for time-independent confounding and marginal structural Cox proportional hazards (Aim 2). Finally, we will identify the demographic, clinical (diagnostic codes, medications, laboratory markers of inflammation (e.g., white blood count) and pharmacological characteristic of Veterans expected to benefit the most from sustained statin treatment using an aggregate machine learning approach (the SuperLearner integrative methodology). Considering the high prevalence of TBI history and its ongoing sequelae,( "a silent epidemic") , especially in the VA, and confirming their synergistic interaction with IMCs may contribute to developing suicide risk-attenuating interventions specifically for those subpopulations. The PI's preliminary data nested in Danish registers, our team's piloting confirming preliminarily a reduction in rates of psychiatric hospitalization (considered a proxy measure of suicide risk) with statins in US Veterans diagnosed with schizophrenia or bipolar disorder and treated with psychotropic medication (Appendix 4C), and our successful evaluation of potential heterogenous effects of an alternative modifiable suicide risk using the specific machine learning algorithms proposed in this project (Appendix 4B) support our hypotheses, integration, and purpose, and overall, project completion capability. Using tailored repurposed medications, such as statins, targeting specifically molecular, cellular and histological mechanisms directly implicated in suicidal behavior, to individuals at risk who are identified by machine learning to potentially derive the greatest benefit from treatment , may provide a much-needed breakthrough in suicide risk management and prevention.

In Aim 1, we will use neurocognitive task scores collected shortly before the SB, to determine which tasks (and therefore, alterations in which cognitive domains) can prospectively predict short-term risk of SB (within the next 3 months). In Aim 2, we will conduct computational modeling on the behavioral data, to extract additional meta-variables, describing latent cognitive processes such as response caution (impulsivity); subjective value of rewarding, punishing, and neutral feedback; perseveration; and tendency to explore new responses, to determine which of these meta-variables can prospectively predict SB. In Aim 3, we will combine these neurocognitive task scores and meta-variables, along with standard indicators of suicide risk such as demographic, self-report, and clinical assessment, in a statistical prediction model, to determine whether inclusion of these cognitive variables and meta-variables can significantly improve prediction of short-term risk for SB in this high-risk Veteran sample.

In this project we will: 1) Develop standardized procedures for identifying, abstracting, harmonizing, and disseminating study-level data from trials of suicide-prevention interventions, and 2) Identify trials of suicide prevention interventions and abstract detailed study-level data in a standardized manner into a publicly accessible database.

Loneliness is a critical psychosocial risk factor for suicidal thoughts and behaviors. Loneliness is also implicated in poor physical and mental health. The cognitive-behavioral model of loneliness posits that interpersonal events trigger unhelpful beliefs about social interactions leading to negative emotional and counterproductive behavioral responses, including suicidal gestures. Consistent with the overarching mission of the CoE, this study will collect pilot data and is aimed at preventing suicidal behaviors by intervening on loneliness, a risk factor of suicide and premature mortality among Veterans who are reporting suicidal ideation. We will recruit 20 veterans who screen positive for loneliness and suicidal ideation to participate in this pilot study. The study will take place at the VA Center of Excellence for Suicide Prevention and will be approved by the Syracuse VAMC IRB. Participants will be enrolled following consent and will complete the baseline assessment. Participants will be administered an 8 week course of CBT-Loneliness. Post-treatment and 30- and 60-day post-treatment follow-up assessments will be conducted. The post-treatment assessment will include an exit interview for participants to describe acceptability of the intervention. We will examine confidence intervals around our effects to inform clinical efficacy for our future fully powered randomized controlled trials. Effect size and confidence intervals will be estimated for loneliness, quality and quantity of social interactions, suicidal thoughts and behavior, and depression. Effects will be calculated at post-intervention, and 30- and 60-day follow-ups.

Mental health care for Veterans with suicidal symptoms is of paramount import to the VA. Unfortunately, VA suicide reports show suicide rates increasing, suggesting a need for enhancing current VA suicide mental health care efforts. While several psychotherapeutic treatments exist for acute suicidality, there is a deficit in validated treatments designed to help Veterans following an acute suicidal episode (Post Acute Suicidal Episode; PASE) such as following a non-fatal suicide attempt after acute risk declines but when they still have ongoing mental health needs and, at times, chronic suicidal symptoms. Available suicide treatments are not designed to promote the recovery and rehabilitation of PASE Veterans. This is a significant gap in comprehensive suicide-focused mental health care. One avenue to close this gap lies through the development of a recovery-oriented psychotherapy for PASE Veterans. Developing recovery-oriented care, "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential" is a VA priority; however, available treatments for suicidal Veterans have limited recovery-orientation. Decades of research into the development of suicide and processes of recovery highlight the importance of increasing Veterans hopefulness about the future, developing a positive self- identity, promoting Veterans' sense of self-empowerment and improved relationships. Continuous Identity- Cognitive Therapy (CI-CT) is a promising new manualized suicide intervention focused on improving Veterans sense of their life story and personal future, with goals similar to recovery-oriented care. CI-CT was developed by the applicant and, as a group therapy, piloted for suicide reduction in Veterans with SMI and was found to have high levels of feasibility, acceptability and (in exploratory analyses) to lead to increased hopefulness about the future and decreased suicidal symptoms. However, CI-CT needs further adaptation for use with PASE Veterans and to enhance its alignment with the fundamentals of recovery-oriented care. The proposed study has three primary stages: First: develop an improved recovery-oriented version of the initial CI-CT Clinician Manual and Veteran workbook to further address components identified as critical for PASE recovery using, (1) an ongoing stakeholder study into the needs of PASE Veterans, (2) recovery literature, (3) scientific and Veteran consumer advisory boards and (4) iterative feedback from an online Veteran PASE sample (N=25) on each section of the workbook. This process will be guided by scientific and PASE Veteran Consumer advisory boards Second: use the materials developed in phase 1 to run 3 one-arm treatment development trials (each with an N of 4-6 PASE Veterans) to test and enhance the CI-CT treatment materials using Veteran feedback and acceptability and feasibility data. Then, with the guidance of our scientific and Veteran consumer advisory boards, use these results to update the treatment. Third: conduct a pilot RCT (N=30) comparing CI-CT for PASE Veterans to an AC (health education) to assess feasibility and acceptability of the treatment materials and research protocol including outcome measures selected and assessment strategy. We will assess rates of recruitment, intervention engagement, and session attendance (feasibility), Veteran satisfaction (acceptability), treatment adherence (fidelity) and preliminarily explore response to CI-CT. Findings will be used to make a final adaptation of the treatment materials and to develop a research protocol for a large scale RCT of CI-CT for PASE Veterans. This study will develop and pilot test a well-specified, group-based intervention tailored to the unique needs of PASE Veterans. The results of the proposed study will provide data to 1) identify adaptations needed to optimize CI-CT for PASE Veterans: 2) identify possible benefits of CI-CT; 3) inform development of a large scale RCT of CI-CT for PASE Veterans.

Objectives The Chronic Effects of Neurotrauma Consortium’s (CENC) Warfighter Epidemiology Cohort was developed to identify phenotypes of comorbidity among deployed Post-9/11 Veterans in order to compare emergence of neurosensory, neurodegenerative, pain, and mental health comorbidity in Veterans with traumatic brain injury (TBI). The Long-term Impact of Military Relevant Brain Injury Consortium (LIMBIC) extension of the Warfighter Epidemiology Cohort will extend the work begun by CENC in which we identified a cohort of Post-9/11 Veterans and comorbidity phenotypes. We also obtained Department of Defense trauma registry (DODTR) data, where available, and Military Health System (MHS) inpatient, outpatient, and pharmacy data that was included in the DoD Mental Health Data Cube. We now propose to expand upon this important data source for over 5 million deployed Service members to include a broader cohort of Post-9/11 era (deployed and non-deployed) Veterans and additional data sources that provide unique opportunities to examine long-term comorbidity phenotypes and develop risk models for comorbidities of interest such as neurodegenerative disease, substance use disorders (SUD), psychological comorbidities, and self-harm behaviors. Research Design and Methodology This retrospective cohort study will accomplish the following goals: 1) Using all sources TBI severity algorithm and NLP/text embedding methods, identify phenotypes of mild traumatic brain injury (mTBI) in DoD and DoD+VA data that incorporate acute injury, mechanism of injury, and blast exposure. A2) Identify prevalence of key comorbidities and outcomes at baseline, before and after mTBI exposure, and in VA (where relevant) and compare those rates by TBI severity and study group. 3) Use deep learning models that incorporate mTBI phenotype, acute and chronic treatment approaches, and emergence of diverse comorbidities to develop risk scores for poor military outcomes and developing key comorbidities. We will use data in DaVINCI to identify a cohort of Veterans who receive longitudinal VA care (at least once a year for three or more years between FY2002 and FY19 [at least one of which is after 2007 when TBI screening was mandated]). We will also identify individuals who did not receive VA care. We will then categorize those with and without VA care as deployed and not deployed, creating four study groups: a) deployed with VA care; b) deployed without VA care; c) not deployed with VA care; d) not deployed without VA care. We will compile VA and DoD data sources and identify key comorbidities (e.g., neuroendocrine dysfunction, SUD, self-harm behaviors) and TBI characteristics. Those data will be used for machine/deep learning models that will develop TBI phenotypes, comorbidity phenotypes, and model risk scores for developing key comorbidities, and optimal processes of care for mTBI. The number of study subjects entering and finishing the study is 5 million. Conducting these analyses for the four study groups will inform TBI pathways of care and illuminate specific target areas to improve acute TBI care and subsequent support systems for chronic care following TBI.

Objectives. Substance use disorder (SUD) and posttraumatic stress disorder (PTSD) frequently co-occur and having one condition worsens the course of the other. Individuals with both disorders exhibit worse functioning across a number of domains than individuals with either disorder alone. This is especially true in residential settings where both disorders are more severe than outpatient settings. Compared to Veterans with a single disorder, Veterans with SUD/PTSD also are more likely to have suicidal ideation and to have attempted suicide. Examining treatable conditions that are associated with improved SUD and PTSD outcomes, such as obstructive sleep apnea (OSA), can maximize treatment efficacy for Veterans at a critical time in recovery. OSA is highly comorbid with both PTSD and SUD with upwards of 67 to 83% of Veterans with SUD or PTSD also having OSA. Further, untreated OSA is associated with worse functional impairment across multiple domains, worse quality of life, worse PTSD, and higher substance use and relapse rates. Importantly, untreated OSA also contributes to higher suicide attempts and completion. Positive airway pressure (PAP) is the gold standard treatment for OSA with large effects on multiple domains of functioning, quality of life, PTSD symptoms, physical functioning, lower depression, and better emotional coping. Unfortunately, screening and treating Veterans for OSA is not a part of clinical practice for SUD or PTSD treatment; as such the average wait time for individuals to get PAP therapy is upward of two years. Despite the widespread dissemination of knowledge regarding the detrimental effects of untreated OSA and the incredible effectiveness of PAP treatment, OSA is rarely screened for or treated in patients with SUD or PTSD, with approximately 80% to 90% of Veterans with OSA remaining undiagnosed and untreated. Methodology. We aim to examine the effects of PAP treatment on Veterans with PTSD and SUD on a 28- day residential unit. We are proposing a randomized controlled study comparing two groups: an early intervention PAP treatment group receiving PAP treatment while on the residential unit, compared to a waitlist control group who will receive PAP treatment at 3-months post-discharge follow-up. Participants will be 194 male and female Veterans on the residential SUD and PTSD unit with SUD, PTSD, and OSA. Our primary aim is to determine the relative efficacy of PAP treatment on the SUD/PTSD unit, as compared to waitlist control, in reducing problematic substance use, PTSD symptoms, and suicidal ideation, while improving functioning among Veterans with comorbid SUD/PTSD at 3-months post-treatment follow-up. We will also compare PAP adherence rates on PTSD/SUD/functioning outcomes within the PAP treatment group (3-months). Finally, we plan on comparing adherence rates between the two treatment groups at the 6-months post-treatment follow- up assessment. Examining OSA treatment for SUD and PTSD is highly relevant to the goals of RR&D and the VA to maximize treatment efficacy for Veterans and has the potential to improve functional and psychological recovery for a highly prevalent and highly impaired population of Veterans. This research will directly impact functional outcomes, SUD recovery, and PTSD symptoms in already vulnerable Veterans struggling with SUD and PTSD. The successful completion of this project will help improve the practices that drive treatment for Veterans who have both SUD and PTSD. The fundamental rationale for this study is to improve the evidence base that informs how patients with SUD and PTSD can attain sustained recovery from both of these disorders. Colvonen - 1

Objectives: The goal of the proposed study is to adapt and expand an existing lethal means counseling (LMC) intervention for peer delivery among firearm owning Veterans. Veteran interventionists will be trained in conducting the adapted intervention and it will be piloted with at least 15 firearm owning Veterans. This intervention will then be evaluated for initial feasibility and acceptability through use of self-report questionnaires and qualitative interviews. Research

Design/Methodology: Between 9-15 Veteran, clinician, and research stakeholders will be recruited to participate in an expert panel to provide feedback on aspects of the intervention that may require adaptation. Furthermore, the expert panel will provide input on methods for assessing intervention fidelity, as well as methods for evaluating the importance of interventionist/participant fit. Based on this feedback, the intervention will be adapted. Then, at least 3 firearm owning Veteran interventionists will be trained to conduct the adapted version of the lethal means counseling intervention. Finally, the adapted intervention will be piloted by the Veteran interventionists with at least fifteen firearm owning Veterans. Initial intervention feasibility and acceptability will be assessed using quantitative and qualitative measures.

Findings: It is hypothesized that the peer-delivered lethal means counseling intervention will be feasible and acceptable. As this is a small single arm trial, statistically significant intervention utility is not anticipated. However, initial trends in Veteran participant openness to changing firearm storage practices and actual change in storage practices over time will be examined to inform future research.

Findings: It is hypothesized that the peer-delivered lethal means counseling intervention will be feasible and acceptable. As this is a small single arm trial, statistically significant intervention utility is not anticipated. However, initial trends in Veteran participant openness to changing firearm storage practices and actual change in storage practices over time will be examined to inform future research. ical Relationships/Impact/

Significance: This investigation has the potential to benefit Veterans and the Department of Veterans Affairs (VA) in several ways. Veterans will benefit by engaging in lethal means counseling, which may increase openness to safe firearm storage practices and will in turn reduce suicide risk. This investigation could yield long-term benefits for the VA by a) expanding suicide prevention efforts into community settings; b) minimizing Veterans’ suicide risk prior to development of suicidal thoughts; and c) incorporating Veterans in ongoing suicide prevention efforts.

Objectives: The goal of VHA’s Health Services Research and Development (HSRD) COnsortium of REsearch (CORE) initiative is to accelerate research that will lead to improvements to care delivered to Veterans. The mission of the “Suicide Prevention Research Impact NeTwork (SPRINT)” CORE is to accelerate health services Suicide Prevention (SP) research that will lead to improvements in care and result in reductions in suicide behaviors among Veterans.

On average, 18 Veterans die by suicide each day. In fact, from 2009 to 2018, more than 64,000 Veterans died by suicide, which is roughly the same number of U.S. military fatalities that resulted from the wars in Vietnam, Iraq, and Afghanistan combined. While heritability estimates for suicidal thoughts and behaviors range from 30- 55%, the genetic basis of suicide remains largely unknown. Our research team has led and participated in many of the largest genome-wide association studies (GWAS) of suicidal thoughts and behaviors to date, including each of the largest conducted in Veteran and military samples. Our most recent work has involved conducting a GWAS of suicide attempts among more than 400,000 Veterans enrolled in the Million Veteran Program (MVP). This study identified multiple pan-ethnic and ancestry-specific genome-wide significant loci associated with risk for attempting suicide among Veterans. Moreover, pathway analyses found evidence of overrepresentation of many biological pathways with high clinical significance, including oxytocin signaling, glutamatergic synapse, cortisol synthesis and secretion, dopaminergic synapse, and circadian rhythm. In parallel, we have been studying a broad array of environmental risk factors for suicidal thoughts and behaviors in Veterans, such as sexual trauma, PTSD, depression, substance use disorders, borderline personality disorder, chronic pain, traumatic brain injury, and sleep disturbance (among others). We are also actively working to identify novel environmental risk factors, including geospatial factors [e.g., socioeconomic status (SES), rurality], many of which have not been previously examined in large-scale genetic studies of suicide risk. We believe that complete understanding of a complex phenotype requires understanding of relevant genetic risk factors, relevant environmental risk factors, as well as the ways in which these risk factors interact. Accordingly, during the next phase of our program of research, we propose to conduct the largest gene-by- environment genome-wide interaction study (GEWIS) of suicidal thoughts and behaviors to date. This work will enable us to identify new ways to improve the identification of high-risk Veterans, while also greatly increasing our understanding of the biological basis of suicide. Our long-term goal is to develop effective screening and intervention strategies to reduce the occurrence of suicide and suicidal behavior among Veterans. The overall objective of this specific application is to discover novel, replicable GxE interactions that increase Veterans' risk for suicidal thoughts and behaviors. The rationale for this research is that identification of genetic variants, environmental factors, and GxE interactions that are reliably associated with suicidal thoughts and behaviors could lead to improved identification of high-risk Veterans and the discovery of additional clinically-meaningful biological pathways. Such findings could, in turn, lead to new and improved treatment and prevention approaches. In Aim 1, we will determine the environmental risk factors most strongly associated with the occurrence of suicide attempts, suicidal ideation, and suicide deaths within the MVP cohort. In Aim 2, we will conduct the largest GEWIS of suicidal thoughts and behaviors to date to identify novel, replicable GxE interactions predictive of suicide attempts, suicidal ideation, and suicide deaths among Veterans. In Aim 3, in order to evaluate the clinical utility of our findings, we will work with our operational partners to determine if the addition of our top genetic risk factors, environmental risk factors, and GxE interactions improves the predictive utility of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) suicide risk algorithm within the MVP cohort. Findings obtained from the proposed work could fundamentally shift understanding of the biology of suicide, lead to new and improved treatments, and improve VA's efforts to identify and intervene with Veterans at risk for suicide. As such, the present application has tremendous potential to advanced VA's mission and improve Veterans' health, safety, and well-being.

One of the key challenges in suicidality research is that outcomes may be multi-determined and rare. The causes of suicidal behaviors may consist of a combination of factors, which vary over time, and between individuals and groups. Risk factors may be distal or proximal, and distal exposures may increase risk for suicide given changes in proximal risk factor(s). Despite literature on suicidality among lesbian, gay, bisexual, and transgender (LGBT) persons, little research has examined LGBT Veterans. We hypothesize that LGBT status is a pre-disposing factor that increases risk due to minority stress, the stress of prior and potentially ongoing discrimination, including military sexual trauma, that may be further increased due to proximal factors such as comorbid mental health and medical conditions, a lack of engagement in care, system and providers lack of awareness or insensitivity to their unique needs, and pain among other factors. With the 2011 repeal of the Don't Ask, Don't Tell (DADT) policy, LGB personnel are currently able to openly serve in the US military, while the status of T personnel remains uncertain. While LGBT Veterans, especially those who served prior to repeal of DADT, may suffer similar discrimination, stigma and stress, they may each have dissimilar suicide risks. One study in the VA found that the prevalence of gender identity disorder diagnosis was >5 times higher than in the general US population, and that the rate of suicide-related events was > 20 times higher than the VA population. However, the engagement of LGBT Veterans in VA care is difficult to estimate: sexual orientation and gender identity (SO/GI) data is not collected in a structured manner. The VA's Evidence Review: Social Determinants of Health for Veterans found "only two articles examined sexual orientation for Veterans and non-Veterans and included only women. No articles addressed gender identity for Veterans and non-Veterans". In addition to LGBT status, there is less study of other suicide risk factors such as pain and opioid prescriptions as well as potential protective factors such as receipt of complementary and integrative health services, which may treat both pain and PTSD. Little is known about how race/ethnicity, gender, morbidity, and treatment intersect with sexual orientation/gender identity to impact suicidality risk. Using VA electronic health record data, will identify LGBT Veterans to ascertain pathways to suicidal behavior, and assess both risk and protective factors related to LGBT individuals in all gender, age, and racial and ethnic groups. In a current project (IIR 16-262), our team is developing natural language processing (NLP) and machine learning (ML) tools to study CIH services' effect on opioid prescribing among Veterans with musculoskeletal disorder diagnoses (MSD) and PTSD. In another project (CRE 12-012), we identified 15,000+ Veterans with suicide attempts near the MSD diagnosis date, and 17,000+ suicide deaths in the cohort (N=5.2 million). That work informs this proposal. Because suicide attempts (SA) might not be captured if a Veteran presents at a non-VA hospital, we will integrate CMS data and develop NLP and ML tools to extract information from VA clinical notes as part of care. The objective and aims of this study are to: Aim 1: Develop informatics tools to identify LGBT Veterans and suicide attempts and events. Aim 2: Characterize suicide risk factors in a national sample of veterans. Aim 3: Examine the differential effect of risk factors on suicide by LGBT status. Achievement of these objectives and Specific Aims promise to expand our understanding of potential areas of unmet need and outreach to all individuals at risk for suicide. This area of VA health services research is in its infancy. Next steps will include: examinations of service(s) use after policy changes and VHA directives such as repeal of DADT (2010) and DOMA (2013), and VHA Directives 1340 and 2011-024 as noted in the letter of support from the VA's LGBT Health Program (10P4Y); using SHEP data to examine differences in satisfaction with care; and sorely needed data on differences in outcomes of care for LGBT Veterans.

Preventing suicide is a top priority for the Veterans Health Administration (VHA). Despite ardent and sustained efforts over the last decade, the suicide rate for VHA patients remains significantly higher than civilians and non- VHA using Veterans. Suicide prevention efforts for high risk VHA patients focus on clinical (e.g., mental health) and service use (e.g., case management) factors. What has yet to be tested is an approach that targets factors in community living, which are better conceptualized as rehabilitative in nature. For it is not only mental and physical illnesses that heighten suicide risk in VHA patients, but also struggles with their sense of self-worth, meaning, and social connections in the community. To help patients with high risk of suicide, this application proposes to adapt and test a promising approach called PREVAIL, which uses Peer Specialists (i.e., Veterans with psychiatric disabilities who have been trained to help others with similar conditions). Peer Specialists do not devalue clinical care but engage in rehabilitative tasks of building a life of self-respect and connectedness in one's local community by offering empathy, hope, and advice based personal experience of mental health recovery. PREVAIL is promising, but still has not demonstrated clinical effectiveness and requires adaptation to address the unique characteristics of Veterans and the VA health care system. This project proposes to use Intervention Mapping, a multi-method, systematic approach using diverse stakeholders, to adapt and pilot PREVAIL. The VHA is the single, largest employer of Peer Specialists and research shows that they can enhance standard clinical care in mental health, physical health, and rehabilitative outcomes. However, Peer Specialists have only just begun to be deployed in suicide prevention efforts. The primary aims of this study are to: 1) Use Intervention Mapping to identify which components of PREVAIL require adaptation to reduce suicidal ideation in high risk VHA patients and to identify implementation strategies useful for the VHA system; and 2) Pilot test the feasibility and acceptability of the adapted PREVAIL, rehabilitative measures, and suicide-related outcomes for use in a rigorous prospective study. With guidance from a steering committee comprised of researchers, VHA leadership, and patients, needs assessment interviews with diverse VHA staff, Peer Specialists, and patients will be conducted to inform the adaptation. Based on results from the needs assessment and the literature on suicide prevention, psychiatric rehabilitation, and peer-based approaches, the steering committee will help adapt PREVAIL. Twelve high suicide risk Veterans with unipolar or bipolar depression will participate in a 3-month "pre- pilot" and provide feedback on how the adapted PREVAIL may be revised. After making any necessary modifications to the intervention, a second group of 12 high suicide risk Veterans with unipolar or bipolar depression will be recruited to participate in a formal pilot test to further evaluate the feasibility and acceptability of recruitment, retention, and assessment procedures. Patients will be from the West Haven and Newington Connecticut medical centers. The Peer Specialists will be from VA Connecticut's Errera Community Care Center, one of VHA's leading centers of innovation in psychosocial rehabilitation and one of the largest employers of Peer Specialists. All participants will receive standard VHA care from the Connecticut campuses while participating in this study. Participants will be assessed at baseline, post-intervention, and 3-month follow-up in their level of functional impairment and community integration; sense of hope, quality of life, meaning, and purpose; and self-views and social support. Chart reviews will also be completed at 3-month follow-up to assess for changes in health care visits involving suicidal behaviors. If acceptability (> 50% enrollment of eligible participants) and feasibility (> 70% of enrollees complete follow-up assessment) are demonstrated, this study will result in a novel rehabilitation-oriented suicide prevention intervention to test in a fully-powered randomized controlled efficacy trial.

PROJECT SUMMARY Despite large-scale, nationwide efforts to better address suicidal behavior (defined as thoughts and behavior) in high-risk Veterans with major depressive disorder (MDD), the development of interventions that target some of the key risk factors associated with suicide in Veterans with MDD remains limited. That is, while much intervention research continues to investigate treatments like cognitive behavioral therapy (CBT) that target behavioral patterns, emotion processing problems, and cognitive styles associated with suicide risk in MDD, deficits in the neurocognitive substrates that underlie these CBT targets remain under-addressed. Cognitive remediation (CR) and rehabilitation have long been a primary treatment for patients with other psychiatric illnesses, like schizophrenia, for improving cognitive functioning and facilitating transfer of cognitive skills to every-day functioning. However, scant work has examined CR that addresses the neurocognitive deficits underlying suicidal behavior in individuals with MDD. Empirical work has identified key executive functioning (EF) deficits that may be specific to MDD patients with suicidal behavior, and meta-analytic work indicates that CR has moderate effect sizes on cognitive functioning, depression, and daily functioning in MDD. Thus, the field is in dire need of work that examines CR as a recovery-oriented treatment approach for MDD patients at risk for suicide. The proposed study aims to collect pilot data to test the feasibility and acceptability of adjunctive neuroplasticity-based CR on key treatment targets delivered via telehealth during this time of COVID-19 in a sample of 36 Veterans with MDD and a history of suicide attempt(s). Specifically, it will test the effects of an adjunctive evidence-based cognitive remediation (CR) therapy (adjunctive to treatment as usual) augmented with manualized "Bridging" sessions on transfer and practice of cognitive control and decision-making/problem- solving strategies for real-world situations and problems, including those that trigger suicidal thoughts. We propose to administer the Neuropsychological Educational Approach to Cognitive Remediation (NEAR, termed CR plus "Bridging" session, CR+Bridging) to a total of 36 Veterans with MDD and a history of suicide attempt(s). The intervention will be delivered in 20 90-minute sessions (2x/week for 10 weeks). Pre-treatment assessments of neurocognitive, clinical, social, and real-world functioning will be conducted, including measures that examine the impact of COVID-19 and its accompanying "social-distancing" restrictions. Post- treatment assessments of the same targets will be conducted to determine clinical response to and feasibility of this therapeutic intervention immediately following conclusion of the intervention (Week 10) and at a follow- up assessment (Week 20). This application is novel in that it constitutes the first implementation of this intervention in Veterans with MDD and suicidal behavior. Consistent with RR&D's SPiRE mechanism, this study is high risk, but it has high potential impact and promise to help improve quality of life for Veterans at high risk for suicide.

Project Summary/Abstract: Among all medical, mental health and substance related disorders, Major Depressive Disorder (MDD) is the leading cause disease burden worldwide; MDD is a major cause of suffering and disability for those receiving their care from the Veterans Health Administration (VHA). Current treatments have limited effectiveness as only about 30% of patients achieve remission with the first antidepressant treatment. By regulatory convention, the term treatment-resistant depression (TRD) is used when a depressed patient has not responded to two or more adequate treatment trials in the current episode. So defined, patients with TRD account for a disproportionately large share of treatment resources and, despite such efforts, are at the highest risk to become chronically ill, develop a complicating substance abuse disorder and/or die by suicide. The CSP 576, VA Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D), showed that adjunctive aripiprazole resulted in a significantly greater likelihood of remission as compared to switching to bupropion. Secondary analyses of VAST-D demonstrated that the advantage of adjunctive aripiprazole among 12-week remitters was sustained across up to six months of therapy and was evident whether or not patients had co-occurring PTSD. In 2019 the U.S. Food and Drug Administration (FDA) reviewed intranasal esketamine as a new therapy for treatment of TRD. The safety and efficacy of esketamine was evaluated in a series of phase III studies that ultimately led to the FDA approval of esketamine (Spravato) for the treatment of TRD in adults. The proposed study will be an open-label, parallel-group, randomized clinical trial of up to 6 months treatment of adjunctive intranasal esketamine vs. adjunctive aripiprazole in Veterans with TRD. This study will assess the efficacy, safety, and acceptability of adjunctive intranasal esketamine in direct comparison to adjunctive aripiprazole for therapy of TRD. The primary hypothesis is that participants receiving adjunctive intranasal esketamine will be significantly more likely to achieve remission after six weeks of treatment as compared to those who receive adjunctive aripiprazole. Depressive symptoms will be assessed by independent evaluators without knowledge of treatment assignment using the Quick Inventory of Depressive Symptomatology clinician rating (QIDS-C), which is a well-validated tool that commonly and is easily translated across other depression inventory scales. The study is powered to be able to detect an absolute difference in remission rates of 10% or larger at 6 weeks. Secondary outcomes of interest include symptom reduction across 6 months of randomized therapy, side effects and other tolerability indices, suicidality, and measures of quality of life and cost-effectiveness.

Project Summary: Suicide rates among veterans with Serious Mental Illness (SMI) are intractably high. Yet, at present available treatments offer only minimal to limited benefits to ameliorate this risk, despite a VA-wide implementation of enriched suicide prevention services and the availability of a national suicide hotline. This dire state represents a serious public health concern and a critical target for interventions. In response to this state, the Rehabilitation Research & Development Service (RR&D)'s Behavioral Health & Social Reintegration Program has highlighted the need for development of suicide prevention interventions that enhance social reintegration, functional outcomes, and improve overall participation in society. Germane to Social Functioning (SF), extensive evidence from basic affective neuroscience research indicates that effective SF requires intact emotion awareness. Speci?cally, emotions are posited to provide crucial information about the signi?cance of social situations and help to guide potential actions to be taken to navigate such situations. Negative emotional experiences in particular have critical informational value in signaling the need to adjust one's current state or activity. As different emotions may call for the use of distinct response strategies, lack of or reduced awareness of experienced feelings may make it dif?cult for individuals to choose response strategies for dealing effectively with social situations, resulting in poor SF. Consistent with these findings, recent reports indicate alexithymia, a transdiagnostic clinical syndrome characterized by poor emotion awareness, to be highly prevalent among veteran and civilians with SMI populations, with a recent large systematic review and meta-analysis indicating alexithymia predicting suicide ideation and behavior (with large and small effect sizes, respectively). Relatedly, previous reports indicate alexithymia has a detrimental impact on treatment outcomes. Altogether, these findings suggest alexithymia may play a key role in impacting suicide risk and treatment response in veterans. Yet, despite its pervasiveness, chronic presentation, link to SMI and poor SF, and impact on clinical outcomes, the putative impact of alexithymia on suicide risk has not been investigated in veterans with SMI at risk of suicide. Building on these findings, the goal of this project is to test the feasibility and acceptability of a novel, blended psychoeducation and digital mHealth (mobile health) intervention designed to target alexithymia and poor SF to reduce suicide risk in veterans with SMI. Employing a proof-of-concept design, 40 participants will attend weekly group psychoeducation sessions targeting emotion awareness and SF along with an innovative mHealth emotion awareness skill training via smartphone to reduce alexithymia, enhance SF, and reduce suicide risk. Results from the present study will provide comprehensive characterization of suicide risk among veterans with SMI, provide preliminary acceptability and feasibility data, and will inform the development of a randomized clinical trial to test the efficacy of the intervention to ameliorate suicide risk in this population.

Project summary: The rate of suicide among women Veterans has grown in recent years and is significantly higher than that of women who have not served in the military. The Veterans Crisis Line (VCL) is a VA suicide prevention initiative that connects Veterans in crisis, as well as concerned family or friends, with supportive resources to prevent suicide. The purpose of this study is to identify the characteristics of women Veteran VCL users and how they compare to male Veteran VCL users, identify the relationship between VCL contact characteristics suicide-related outcomes among male and female Veteran VCL users, and identify the experiences and recommendations of women Veteran VCL users. Through analysis of administrative clinical data and in-depth interviews with women Veteran VCL users, along with input from a multi-stakeholder advisory board, this research will serve to develop clinical recommendations and implementation strategies to strengthen suicide prevention initiatives specifically for vulnerable populations of women Veterans. Specific Aims: The specific aims of this study are to: (1) describe and compare the demographic and VCL contact characteristics (reason for call, call outcome, and VCL risk rating) among female and male Veteran VCL users; (2) examine the relationship between VCL contact characteristics (risk rating, referral, identified needs) and subsequent fatal and non-fatal suicidal self-directed violence (S-SDV), assessing for variation by Veteran gender, among female and male Veteran VCL users who use VHA services; (3) understand women Veterans’ experiences with and recommendations regarding VCL services, including the use of VCL for both acute and more upstream suicide prevention.

Psychiatric hospitalization is a critical opportunity to provide treatment to reduce the risk of suicide and lay the groundwork for functional recovery. In fact, the period following psychiatric hospitalization presents the greatest risk of death by suicide for Veterans. Despite psychiatric hospitalization being a vital time for intervention, there are no suicide-specific evidence-based psychotherapies (EBPs) that can be feasibly delivered during a typical VHA inpatient stay. Importantly, suicide-specific inpatient interventions are primarily focused on reducing the reoccurrence of suicidal behavior and have limited or no focus on directly targeting other aspects of functional recovery. Preventing suicide during a crisis is only a short-term solution if we fail to assist patients in building a life they deem worth living. Our research over the past several years has been focused on addressing this gap and overcoming barriers to implementing psychosocial interventions in an inpatient setting. Acceptance and Commitment Therapy (ACT) is a psychosocial intervention well suited to both preventing suicide and enhancing functioning, but we were not aware of any ACT-based treatment protocols designed to specifically target suicide risk. We consulted with leading ACT clinicians and researchers to develop and manualize "ACT for Life", a brief, transdiagnostic, recovery-oriented, inpatient, intervention for Veterans hospitalized due to suicide risk. The individual intervention involves 3 to 6 inpatient sessions and 1 to 4 outpatient sessions focused on skills generalization and treatment engagement. We conducted a randomized controlled pilot study evaluating the acceptability of ACT for Life and the feasibility of the planned design for the proposed randomized controlled efficacy trial. Results of this rigorous pilot study support the acceptability and feasibility of ACT for Life. Nearly all Veterans reported that they believed they benefitted from ACT for Life. Preliminary outcomes suggest that ACT for Life may improve functioning and reduce suicidal behavior following hospitalization due to suicide risk. However, a full- scale clinical trial will be necessary to definitively evaluate the efficacy of ACT for Life. To accomplish this goal, we are proposing to conduct a randomized controlled trial of ACT for Life versus Present Centered Therapy in 278 Veterans hospitalized for suicide risk to examine outcomes of suicidal behavior and changes in functioning over a one-year period following psychiatric hospitalization. The specific aims of this study are to determine the efficacy of ACT for Life for preventing suicidal behavior and maximizing functional recovery, and to examine candidate ACT for Life treatment mechanisms. Participants will complete assessments prior to treatment, before discharge from the inpatient unit, and at one-, three-, six-, and twelve-months following discharge. The proposed randomized controlled trial of ACT for Life has the potential to fill the VHA's need for empirically-supported inpatient interventions that can be delivered during a typical inpatient stay, are recovery oriented, and prevent future suicidal behavior. If results support the efficacy of the ACT for Life intervention, ACT for Life will be the first and only inpatient, evidence-based psychotherapy known to prevent suicidal behavior among Veterans.

Reducing Veteran suicide has been one of the Department of Veterans Affairs (VA) top priorities for the past decade. Efforts to address Veteran suicide have typically included downstream approaches focused on suicide risk management for those who have previously been identified to be at elevated risk. The Joint Commission, however, released a Sentinel Event Alert1 highlighting findings that a substantial number of those who died by suicide had not presented to mental health clinics or psychiatric units. Research suggests that many individuals, including Veterans who die by suicide had been seen by their primary care provider or in other medical settings within the year of their death2-4. Based on this, the Office of Mental Health and Suicide Prevention (OMHSP) tasked an interdisciplinary workgroup to develop an evidence-based, population-level approach to identifying suicide risk in Veterans who present in a wide range of healthcare settings. From this work, the largest implementation of a system-wide suicide risk screening and evaluation initiative within a U.S. healthcare system was developed - the VA Suicide Risk Identification Strategy (VA Risk ID). VA Risk ID is comprised of three stages: The first stage utilizes the Patient Health Questionnaire-95, item 9 as a primary screen to maximize sensitivity; the second stage uses the Columbia Suicide Severity Rating Scale Screener6 as a secondary screen to maximize specificity, and the third stage uses the VA Comprehensive Suicide Risk Evaluation (CSRE) to gather information related to clinical impressions of acute and chronic suicide risk, which are used to develop a risk mitigation plan. The goal of the proposed project is to employ a Sequential Multiple Assignment Randomized Trial (SMART) design to improve the implementation of VA Risk ID's three-stage screening and evaluation process to fidelity (in correct sequence, by the appropriate provider, and within the designated time frame) for Veterans receiving annual screenings for depression and PTSD. Within the SMART, two evidence-based implementation interventions will be compared to Implementation as Usual (IAU): Audit and Feedback (A/F) and Audit and Feedback plus External Facilitation (A/F+EF). IAU is available to all sites and includes proactive technical assistance, tools, training and a quality assurance dashboard. A/F will provide sites with frequent, non-punitive reports that include information on: individual site performance and comparisons with national average (based on VA Risk ID clinical performance measures), specific areas of improvement and suggested actions. A/F+EF groups will receive A/F reports and external facilitation, which includes strategies such as, stakeholder engagement, identification of barriers and facilitators and problem-solving. This project will occur over three phases: run-in phase, intervention phase I and intervention phase II. The unit of intervention is the site and randomization will occur at the site level. A sequence of decisions regarding which interventions sites will receive during intervention phases I and II are built into the study design. Decisions will be based on site performance. Specifically, only sites who do not meet the program office's benchmark for adequate performance (i.e., completion of secondary screening and CSRE for 80% or more of eligible patients) will be randomized to receive the implementation interventions, beginning with the less intensive intervention (i.e., A/F) for 10 months. Sites that still do not meet the performance benchmark after receiving A/F, will be re- randomized at the end of Phase I to continue receiving either A/F or a more intensive intervention consisting of A/F + external facilitation (A/F + EF) for another 10 months. The primary aim seeks to understand whether the addition of A/F during the initial phase will significantly improve performance measure scores compared to IAU alone; a secondary aim will examine whether A/F+EF significantly improves performance scores compared to A/F alone. Exploratory aims will consider contextual factors which may influence response to implementation interventions as well as clinical outcomes related to VA Risk ID.

Research: Veterans of the U.S. military die by suicide at a rate of two to six times that of their civilian counterparts. Suicidal ideation (SI) and suicide attempts (SA), cardinal precursors to death by suicide, occur at significantly greater frequency than death and cause immense individual and societal burden, yet relatively little is known about their pathophysiology. This is especially so in posttraumatic stress disorder (PTSD), a signature injury of the wars in Iraq and Afghanistan. High rates of comorbidity and inflated prevalence of both suicidality and PTSD in Veterans, highlights the urgency of advancing understanding of the shared and distinguishing neural mechanisms between these. Evidence of trauma- and stress-related synaptic loss and large-scale alterations in intrinsic connectivity networks in brain regions implicated in mood, cognition, and behavior exists in both SI/SA and PTSD literature. However, a major obstacle in field is the scarcity of neurobiologically-based studies of SI/SA in PTSD cohorts. Preliminary data supports the notion that the location and pattern of synaptic alterations may interact with individual and environmental characteristics to affect clinical presentation and symptom severity. Specifically, Veterans with PTSD endorsing SI appear to have a neural signature of synaptic alterations distinct from PTSD symptom severity, depression, and age. Extending this work, state-of-the-art multimodal neuroimaging and behavioral assessment sessions will be conducted in 96 Veterans across 3 study groups (n=32/group): PTSD only; PTSD+SI; PTSD+SA. Robust, complimentary evidence of a unique pattern and location of synaptic alterations will be demonstrated using (a) whole-brain vertex-wise structural magnetic resonance imaging (MRI) to measure cortical thickness, (b) resting-state functional connectivity MRI (rs-fcMRI) to measure global brain connectivity (GBC), and (c) diffusion MRI to measure diffusion GBC (dGBC), a measure of microstructural architecture and connectivity. Veterans will be matched on age, sex, PTSD symptom severity, and history of traumatic brain injury. This study may identify biomarkers of treatment targets in two of the operational priority areas for the VA ? suicide and PTSD, inform novel drug development of efficacious pharmacologic interventions, and ultimately advance the field making way to alleviate suffering of millions of individuals ? Veteran and civilian alike - struggling with suicidality. Candidate: Dr. Averill has demonstrated an unwavering commitment to improving Veterans? mental health care, with emphasis on PTSD and suicide prevention for well over a decade. Short-term goals include receipt of the CDA-2 to both advance her expertise through rigorous training objectives (focused on the neurobiology of SI/SA, multimodal neuroimaging, and statistics) and to provide data for future funding as she establishes a niche program of research in the National Center for PTSD-Clinical Neurosciences Division (NCPTSD-CND). Long-term goals include becoming a thought leader in the areas of suicide prevention and PTSD in Veterans through empirical investigations aimed at informing novel drug development and improved prevention, diagnostics, identification of biomarkers of risk and resilience in SI/SA, and treatment options. Environment: The infrastructure, quality of mentors, supplementary funding support, technology, and Veteran-focused research environment available at the National Center for PTSD-Clinical Neurosciences Division and Yale are unparalleled. This offers unique opportunity to support Dr. Averill in her transition to independence though exceptional targeted training/mentorship and to conduct a low cost/high yield study with great potential to advance the field, lead to improved outcomes for Veterans, and set a foundation for a successful VA-centric career.

Self-destructive behaviors are frequently comorbid with posttraumatic stress disorder (PTSD) among Veterans, where they are linked to increased distress and impairment. Self-destructive behaviors encompass those with the potential for immediate injury (e.g., [suicidal and nonsuicidal] self-directed violence) and those with more distal consequences (e.g., substance use, disordered eating). The proposed research aims to apply advanced quantitative methods to model interrelations of [PTSD and depressive symptoms] and self-destructive behaviors at both the group and individual levels. In Aim 1, network models of relations of these constructs will be developed in a gender-balanced sample of Veterans from all service eras (N = 1,187). Results will identify which [symptoms bridge (i.e., connect) to suicide-related outcomes and other nonsuicidal self-destructive behaviors and whether these differ by gender.] Analyses will also test whether baseline bridge symptoms predict self-destructive behaviors [(specifically suicide-related outcomes)] at 12-month follow-up. Results will be validated in a separate gender-balanced sample of post-9/11 Veterans (N = 1,494). Aim 2 is to examine real-time, dynamic changes in network models of PTSD-related constructs and self-destructive behaviors at the intrapersonal level. A new sample of Veterans (target N = 60, 50% women) who meet criteria for subthreshold/threshold PTSD and report recent suicidal ideation and at least one other self-destructive behavior will be recruited to complete an ecological momentary assessment (EMA) protocol reporting on these constructs. Multilevel autovector regression analysis techniques will be used to model real-time changes in networks of PTSD and depressive symptoms, and self-destructive behaviors. The candidate is a postdoctoral fellow in clinical psychology at the Women's Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System. Research and training will take place within the environment of VA Boston Healthcare System and its academic affiliate, Boston University under the supervision of a distinguished mentorship team with content and methodological expertise relevant to the proposal. The training aims associated with this proposal include: 1) Gain advanced knowledge of models of traumatic stress and self- destructive behaviors; 2) acquire skills in advanced quantitative methods for analyzing complex, multivariate relations; 3) gain expertise in EMA data collection and analyses; and 4) engage in professional development to prepare the candidate for a successful career as a VA clinical investigator. The research and training associated with this CDA2 will prepare the principal investigator to achieve her immediate goal of preparing a successful VA Research Merit Award application to study the impact of trauma-focused treatments on mechanisms of self-destructive behaviors identified in this proposal. The candidate's long-term goal is to become an expert in the dynamic processes of psychological mechanisms maintaining self-destructive behaviors secondary to trauma exposure. Through this expertise, the candidate aims to produce knowledge that can be used to enhance trauma-focused treatments and develop personalized, adaptive intervention/assessment tools for self-destructive behaviors.

Substance Use Disorders (SUDs) are common in Veterans Health Administration (VHA) patients and are closely linked to some of the most pressing problems facing Veterans including overdose, suicide risk and homelessness. The VHA is a national leader in providing access to high-quality SUD treatment as well as the development of an evidence-base to inform and improve care for Veterans with SUDs. However, key gaps remain, particularly for Veterans who have co-occurring SUDs and psychiatric and/or medical conditions. Nonetheless, there is the clear potential to expand the positive impact of substance-oriented services within the VA by improving access to behavioral health treatments and integrating these services into addictions treatment. Mark Ilgen, Ph.D. has developed a research portfolio focused on tailoring SUD treatment to address patient comorbidity by conducting Veteran-centric health services research on addiction. The two primary thematic aims of this work are: Aim 1: to improve treatment outcomes and reduce risk of adverse events among Veterans with co-occurring SUDs and chronic pain; and, Aim 2: to decrease the risk of suicide among Veterans with SUDs. These two thematic areas directly relate to positive treatment outcomes, as well as reducing the likelihood of adverse events, among Veterans with SUDs. Dr. Ilgen’s contributions to these areas are evidenced by his grant-funded research with support from the VA Health Services Research and Development (HSR&D), the VA Office of Mental Health and Suicide Prevention, the Department of Defense, National Institute on Drug Abuse, and the National Center for Complementary and Integrative Health. The Research Career Scientist Award will support his continued research, as well an expanded role in mentorship and training of the next generation of HSR&D researchers. This research portfolio has the potential to address some of the most-critical and vexing behavioral health-related priorities in VHA and improve care for some of the most challenging and highest-risk Veterans treated within the VHA system.

Suicidal behavior is a complex phenomenon, ranging from low-lethality, low-intent impulsive acts to high- lethality high-intent suicidal acts, and thus likely to be associated with multiple underlying subtypes. Genetic associates of suicidal behavior have been identified in several studies, yet the effect sizes for are usually modest, possibly because of the heterogeneity in the suicidal population and the behavior. Using the Million Veteran Program Gamma computational platform, we propose a unique combination of statistical and machine learning methods to develop our subtypes based on Electronic Patient Records and self-reports; followed by a careful genomic analysis of the resulting subtypes compared to two control groups chosen from the same cohort, with and without mental health disorders. This project aims to develop sophisticated diagnosis tools for preventing future suicidal behavior in US Veterans at high risk. Moreover, the biomarkers identified from this study will be directly applied for validation in the PI and co-investigators' longitudinal study of high-risk VA patients, a natural validation sample from the same population; promising a combination of the power of both studies.

Suicide cognitions are significant risk factors for suicidal ideation and behaviors. Reducing the tendency to experience these thoughts may be life-saving. Dr. Dillon has developed and piloted an interpretation bias modification intervention that reduces both hostile interpretation bias and anger outcomes. The current project will use this paradigm to develop an intervention to reduce suicidal cognitions for Veterans with posttraumatic stress disorder (PTSD). In addition to targeting suicide cognitions, the project will also assess the impact of reductions in hostile interpretation bias on suicide risk and functioning. Hostile interpretation bias is a cognitive tendency that is associated with problematic anger. Moreover, recent research by Dr. Dillon and others shows a consistent association between anger and risk for self-directed violence. In fact, two recent ecological momentary assessment (EMA) studies conducted by Dr. Dillon in conjunction with Drs. Kimbrel and Beckham have shown that: 1) anger was the emotion most strongly associated with self-injurious thoughts and behaviors among Veterans with a history of self-directed violence; and 2) that anger was highly predictive of future self-injurious thoughts and behaviors among Veterans. Thus, we hypothesize that hostile interpretation bias may be a promising target for suicide prevention efforts. Accordingly, we propose to pursue the following specific aims: Aim 1(a). Develop a mobile interpretation bias modification intervention entitled Mobile Intervention for Suicidal Thoughts (MIST) to reduce cognitions that contribute to elevated suicide risk. We will develop content to target cognitive factors that contribute to suicide risk and program this content into a mobile application similar to an existing app developed by the team to target hostile interpretation bias, entitled MIRA. Aim 1(b). Use a successive cohort design to refine the MIST intervention among Veterans with PTSD, problematic anger, and elevated suicidal ideation. To refine the intervention developed in Aim 1(a), the intervention will be tested in two cohorts (each n = 5) of Veterans with PTSD, problematic anger, and suicidal ideation. After each cohort uses the MIST application for four weeks, a quantitative and qualitative evaluation will be conducted with each Veteran. Revisions will be conducted before the next cohort is treated. Aim 2.Assess the impact of reductions in suicide cognitions and hostile interpretation bias on suicide risk and functioning. After using the MIST intervention for four weeks, participants will use the MIRA intervention for another four weeks. For the duration of the study (all eight weeks of treatment), EMA data will be collected to evaluate the impact of both interventions on suicide risk and daily functioning.

Suicide has been an increasingly prominent health concern among Veterans over the past 20 years. The Department of Veterans Affairs (VA) National Strategy for Preventing Veteran Suicide calls for robust and innovative solutions to existing suicide prevention efforts, including improvements to existing psychotherapeutic interventions. Effective suicide prevention interventions should identify and target mechanisms of suicide risk in the most efficient manner possible. One strategy includes a skills-based approach to reducing psychological inflexibility (cf. distress) related to suicidal ideation, thereby preventing suicidal thoughts from progressing to more severe forms of self-directed violence. Moreover, distilling these treatment components into a format that is more easily disseminated (i.e., single session, web-based) would improve Veteran access to effective suicide prevention interventions. Unfortunately, few clinical suicide prevention interventions have adopted either of these approaches, and none to date appear to have combined them in a manner that would provide an effective adjunctive suicide-specific intervention that could be administered across both traditional and non-traditional (e.g., primary care, emergency clinics) mental health settings. To that end, the Principal Investigator (PI) previously developed and tested a web-based intervention designed to reduce psychological inflexibility related to suicidal ideation, termed Re-Evaluating Suicidal Thoughts (REST). In a randomized clinical trial (RCT) of 98 non-Veteran outpatients, REST reduced psychological inflexibility and severity of suicidal ideation compared to controls. In a one-arm acceptability trial of 24 Veteran outpatients, REST was rated as highly relevant, helpful, and easy to use. The objective of the current proposal is therefore to evaluate the effectiveness of REST as an adjunctive suicide prevention intervention among Veterans in an integrated health care setting. The specific aims are to: evaluate the effect of REST on psychological inflexibility of suicidal ideation (Aim 1); evaluate the effect of REST on suicidal ideation severity and self-directed violence (Aim 2); and identify the therapeutic mechanism of REST in reducing suicidal ideation severity (Aim 3). Primary hypotheses include: compared to controls, REST will result in lower psychological inflexibility of suicidal ideation at one-week follow-up (Hypothesis 1) and lower suicidal ideation severity and reported self-directed violence at one-month follow-up (Hypothesis 2a and b); and that reductions in psychological inflexibility will account for reductions in suicidal ideation severity and self- directed violence (Hypothesis 3a and b). To accomplish these aims, the PI will recruit Veterans with current suicidal ideation (N = 150) to be randomized to receive REST or maintain treatment-as-usual (TAU control). Self- report measures of psychological inflexibility and severity of suicidal ideation will be administered at pre- intervention, one-week, and one-month follow-up. Reports of self-directed violence (e.g., plans, preparatory behaviors, and attempts) will be collected via clinical interview at baseline, one-week, and one-month follow-up. The aims of this study will in part address key aspects of VA's National Strategy for Preventing Veteran Suicide. Specifically, this RCT "evaluate the effectiveness of Veteran suicide prevention interventions" (Objective 13.1). Demonstrating the effectiveness of a web-based suicide prevention intervention will further "promote timely access to intervention and effective care for Veterans with a heightened risk for suicide" (Objective 8.2). The activities in this proposal will position the PI to become a leading independent investigator in VA with a focus on clinical interventions for suicide prevention. The overall training goal of this proposal is to develop an expertise in the development and empirical evaluation of scalable clinical interventions that address suicide risk. Training aims include expertise in clinical trials research, clinical interventions for suicide risk, and leveraging technology to enhance suicide prevention efforts. The research and training aims included herein will position the PI to submit a VA Merit Award, grow a research program rooted in evidence-based approaches to Veteran suicide prevention interventions, and become a leading clinical investigator in VA suicide prevention research.

Suicide is a lethal problem for Veterans. A major challenge in predicting and preventing suicide is that ideation and suicide behaviors fluctuate over time, as do the cognitive, emotional, and physical states that precede them. Recent advances in mobile health technology hold promise for intensively measuring risk factors for suicide that are proximal, time-varying, and occur naturalistically in daily life using smartphones. Cognitive factors - including cognitive control and social cognition - play a role in suicide risk; to date, however, mobile health tools have not been adopted to objectively measure cognitive performance fluctuations in Veterans. To address this gap, we propose to use our previously developed mobile health tool for measuring cognitive control and social cognition in the daily lives of Veterans with elevated suicide risk. Drawing on our experience delivering mobile health assessments in individuals at-risk for suicide, we will examine the dynamic relationships between cognitive performance and suicide, as well as other contextual variables associated with suicide risk. A transdiagnostic sample of Veterans with current suicidal ideation will complete concurrent mobile cognitive tests (MCTs) and ecological momentary assessments (EMA) within a two-week intensive assessment. Our aims are to identify associations between cognitive test performance and constructs closely linked to suicide risk (restricted coping ability, negative interpersonal beliefs, ideation). We also seek to examine how relationships established in the intensive mobile health longitudinal dataset relate to real-world suicide outcomes which we will derive from the electronic medical record and telehealth assessments. We will use the dataset to identify subtypes of Veterans based on their temporal pattern of suicidal ideation and examine associations between subtypes and real-world suicide outcomes. Finally, we will explore the role of specific context variables (e.g., sleep) in suicide risk. Deliverables from this project will include an intensive longitudinal dataset that overcomes limitations of traditional static laboratory-based assessments. This dataset can be leveraged to assess additional real-time proximal risk factors associated with suicide in longitudinal studies and interventional research on the cognitive underpinnings of suicide.

Suicide is one of the leading causes of death among military personnel. While multiple risk factors have been implicated in suicide behavior, sleep disruption is consistently associated with elevated suicide risk. Unfortunately, the exact link between sleep disruption and suicide risk is unclear, and research is mixed regarding which mechanisms are driving the sleep-suicide link. We propose to conduct a longitudinal, multimodal assessment of the sleep, suicide, and hypothesized mechanisms driving the link between sleep and suicide. One hundred and forty Veterans hospitalized for suicide attempt or ideation with plan and intent will be recruited during inpatient hospitalization. Veterans will be provided with activity monitors called actigraphs while on the unit and an Ecological Momentary Assessment (EMA) program will be downloaded onto their phones upon hospital discharge. Participants will be assessed daily for 8 weeks using EMA and actigraphy, with follow up assessment at 2, 4, 6, and 8 weeks and 6 months post-hospital discharge. Sleep, suicide, emotion regulation, emotional reactivity, and impulsivity making will be assessed using a combination of actigraphy, sleep diaries, EMA, in-laboratory tasks and self-report measures. EMA devices will be able to capture daily changes in mechanisms of interest, sleep parameters, and suicide behaviors. The primary objective of the study is to gain a clearer understanding of the relationship between sleep and Veteran suicide during a particularly high-risk transition period from inpatient to outpatient psychiatric care. A combination of dynamic structural modeling (DSEM), latent growth modeling, and multiple linear regression will be used to evaluate the utility of our conceptual model in predicting the combined effects of sleep disturbance, emotion reactivity and regulation, and impulsivity in the prediction of suicide risk.

Suicide prevention among rural veterans is an urgent VA priority. The COVID-19pandemic has exacerbated rural-urban disparities in health access and in suicide risk. Telehealth can improve health care access for rural veterans but there is insufficient evidence about its effectiveness for reducing suicides among veterans. In 2016, VA’s Offices of Rural Health (ORH) and Connected Care (OCC) began distributing video-enabled tablets to veterans with access barriers to facilitate their participation in home-based telehealth. VA-issued tablets present an opportunity to pilot a scenario in which veterans face fewer barriers to accessing home-based telehealth. The proposed project will be the first study to examine the impact of telehealth tablets issued by the VA during the COVID-19 pandemic on suicide-related hospitalizations and suicide deaths. We will use a modified difference-in-differences study design to compare suicide outcomes for veterans who received VA-issued tablets during COVID-19 and veterans who never received VA-issued tablets, one year before and one year after tablet shipment date. Given concerns of the rural/urban technological digital divide, we will stratify our analyses by rurality in order to assess the differential effectiveness of tablets across rural and urban veterans. While worse broadband access could result in tablets being more effective for urban veterans, the positive effect of tablets could be greater for rural veterans due to larger barriers to mental health care access they face at baseline. Subgroup analyses of “ReachVet” veterans who the VA identifies as highest risk of suicide will inform whether the VA needs to adopt differential strategies for veterans with different levels of suicide risk. These findings will inform future research, policy and implementation efforts for VA’s suicide prevention strategies, VA’s distribution of telehealth tablets and VA’s home telehealth policies.

SUMMARY Dr. Haghighi's research specialty is in medical epigenetics with applications to traumatic brain Injury (TBI), depression, and suicidal behavior. These epigenetic studies involve how genes are differentially transcribed and regulated, within human clinical and postmortem brain samples, providing a snapshot of potential transcriptional regulatory abnormalities associated with disease neuropathology. Dr. Haghighi's clinical studies show how environmental exposure affects the epigenome. Specifically, in her studies involving traumatic brain injury, she investigates how response to repeated blast-exposure induces long-term transcriptional regulatory changes resulting in symptoms of sleep disturbances, anxiety, cognitive deficits and depression and PTSD. Additionally, she investigates how the role of stress, specifically chronic stress, induces epigenetic changes associated with depression and suicide in the Veteran population.

Supporting Relationships to Reduce Suicide Risk: A Randomized Control Trial of the Brief Relationship Checkup

The current 2-year career development award (CDA-1) proposal is designed to prepare Dr. Michael Ruderman, a VA Psychiatrist with foundational knowledge of advanced research methods, for a career in VA conducting research as a psychiatrist scientist who will advance innovation in suicide prevention and intervention strategies identifying and targeting causal mechanisms for suicide that are amenable for intervention. Dr. Ruderman will accomplish this goal through the pursuit and completion of training activities, support from an expert mentoring team, and completion of a research project aimed at bridging the gap between causal inference research methods and clinical knowledge to inform suicide interventions. The CDA-1 project will ultimately generate pilot information about causal factors for suicide risk with refinement based on expert elicitation for Dr. Ruderman's submission of a CDA-2 application. Dr. Ruderman's proposed CDA-1 project supports VA's top clinical priority preventing suicide. Moreover, this proposal is directly aligned with VA's mandate to prioritize research that can help develop targeted suicide interventions by finding out why certain Veterans are at risk of suicide. Despite VA's strong predictive analytics for stratifying Veterans at risk for suicide, the mechanisms leading to suicide are poorly understood. This lack of knowledge has impeded the innovation of targeted and effective interventions available. National suicide research agendas urge investigators to leverage existing data and determine potential causal targets that could define or develop effective suicide interventions. However, few large-scale databases exist that would have the capacity to harmonize and link to the right breadth and depth of information to successfully detect causal targets for a rare (yet, profound) outcome like suicide. Thus, this CDA-1 proposed research leverages Dr. Amy Byers' (primary mentor on the CDA-1) CSR&D Merit award project (CX001119), which uniquely formed a longitudinal cohort of 5 million Veterans aged 50 years and older including, currently, nearly 12,000 suicide deaths and data on demographics, inpatient, outpatient, medications, labs, and morbidity. The CDA-1 project will expand upon Dr. Byers' research on late-life suicide risk looking at prognostic factors and fill a significant gap in the field, causal inference, complementing predictive analytics in suicide risk research at VA. Furthermore, focusing on mid-to-late-life Veterans is ideal because it supplies targeted information in this understudied and highly vulnerable group, who have the highest number of lives lost to suicide (~70% of all Veteran suicide deaths), as well as make up over 70% of the Veteran population. Discovering candidates from large secondary data requires an approach that can extract causal information efficiently while also prioritizing likelihood of clinical utility. Data-driven causal methods have the potential to do this, but only if such methods are tightly linked with existing clinical and other scientific knowledge. Therefore, we propose an approach where we: first (Aim 1) utilize causal discovery techniques to identify preliminary causal candidates for suicide in Veterans aged 50 years and older; and, then, second (Aim 2) develop a protocol to elicit clinical expertise on potential mechanisms of suicide, which will provide necessary pilot information for a CDA-2 application. Such a biphasic approach ensures expert knowledge is integrated with computational analysis to maximize likelihood of clinical utility for suicide prevention. To this end, the aims and training of this 2-year CDA-1 will prepare Dr. Michael Ruderman to submit a CDA-2 application clearing a path toward an independent research program as a computational psychiatrist, bridging methods to institute actionable change, reducing suicide risk for Veterans, and empowering their providers.

The evidence is clear: team-based behavioral healthcare improves outcomes and satisfaction for individuals with mental health conditions. However, healthcare teams do not develop naturally and require targeted support to form, function effectively, and be sustained. Using facilitation techniques and common measures, this QUERI Program will enhance and inform team-based care for Veterans with behavioral health conditions. Specific aims include: Understand and enhance coordination, quality, equity, and outcomes of care for Veterans treated within interdisciplinary VA treatment teams and via shared care across healthcare disciplines; Advance measurement-based care delivery strategies that enhance personalized, proactive, and patient-driven care for Veterans; and Apply implementation methods by developing, evaluating, and refining new tools and resources to support the use of facilitation to implement clinical programs and practices that are responsive to VA priorities.

The main objective of this study is to develop and test the use of public messaging to increase treatment seeking among Veterans at risk for suicide and resistant to seek mental health care following separation from military service.

The main objective of this study is to use data from STARRS to identify service-related predictors of suicide following separation from active duty service.

The objective of this HSR&D Career Development Award-2 Proposal is to facilitate Dr. Jason Chen's transition into an independent, VA mental health services research career focused on intervention development for Veterans at high-risk of suicide. The goal of the project is to develop a multicomponent intervention focused on increasing social connectedness among Veterans with recent psychiatric hospitalizations through supported participation in community activities. This intervention will be informed by input from Veteran, VHA clinical (e.g. psychiatrists, administrators), and community (e.g. non-profit organizations, family) stakeholders. Research Plan: Although multiple national efforts have been introduced to address Veteran suicide, suicide rates remain high. Systematic reviews have identified few interventions that effectively decrease suicide risk. One promising area for intervention is social connectedness which has been identified as a strong protective factor. However, few interventions directly target social connectedness among at-risk individuals. Increasing Veteran participation in community activities may be one way to improve social connectedness difficulties. The current project proposes the following research aims: 1) Identify Veterans' current behaviors, needs, and preferences for community engagement following psychiatric hospitalization, 2) Identify VHA staff and community stakeholder perceptions and perceived needs related to Veteran community engagement following psychiatric hospitalization, and 3) Develop and pilot a multicomponent, peer-support facilitated intervention for increasing social connectedness among Veterans at elevated risk of death by suicide. Expected outcomes from these aims include clinical toolkits for VA and community stakeholders, academic manuscripts and presentations, and two HSR&D IIR submissions over the course of the CDA award period. Career Plan: Dr. Chen has assembled a mentorship team who will support his development as a VA mental health services researcher. Team members include: Steven Dobscha, MD (Primary Mentor), Julie Lowery, PhD (Co-Mentor; Implementation Science/Qualitative Methods), Paul Pfeiffer, MD, MS (Co-Mentor; Peer Support Intervention Development), Sarah Ono, PhD (Consultant; Veteran Engagement/Qualitative Methods), and Alan Teo, MD, MS (Consultant; Social Support). Dr. Chen will also have three Operations Partners/Consultants: Aimee Johnson, LCSW (Office of Mental Health and Suicide Prevention), Tracy Weistreich, PhD (Office of Community Engagement/Center for Compassionate Intervention), and Jason Zimmerman, CPSC (Peer Support Lead). Dr. Chen and his mentorship team have developed the following training goals which align with his research aims: 1) Develop advanced qualitative health services research skills, 2) Acquire intervention development and evaluation skills for conducting clinical trials, 3) Gain didactic and applied training in implementation science, and 4) Achieve further competence in program development to support effective VA-community collaborations including peer support. Dr. Chen will achieve these training goals through coursework, mentorship/consultant meetings, and applied training during CDA research activities. Following the completion of these training goals, Dr. Chen will be well-prepared to become an independent VA HSR&D mental health services researcher with expertise in utilizing qualitative methodology, clinical trials, implementation science, and program development to enhance current Veteran suicide prevention efforts.

The overarching objective of this project is to develop improved statistical models for predicting risk for suicide among Veterans receiving VHA services.

The proposed project seeks to conduct analysis of suicide among Veterans discharged from VA psychiatric inpatient units. To identify risk and protective factors among Veterans discharged from acute psychiatric inpatient units.

The proposed randomized control trial will examine the efficacy of a brief behavioral treatment for reducing suicidal ideation and for increasing reasons for living in older Veterans at risk for suicide. Two common issues in older adults, functional disability and executive dysfunction, increase suicide risk and will be examined as moderators and mediators of treatment outcomes. The proposed study will examine Problem Solving Therapy (PST) using a protocol that teaches skills to address emotional and practical barriers to effective problem solving. The VA usual care practice of collaborative safety planning will be the control condition, herein referred to as enhanced usual care (EUC). For participant safety, Veterans enrolled in PST will also receive EUC. The study design is random assignment to the treatment, PST plus EUC, or the control condition, EUC only. Both the treatment and the control are evidence-based interventions delivered in six sessions. The study will occur at VA Palo Alto (primary site) and VA Syracuse/VA Canandaigua (secondary site). The assessments and treatments will be conducted entirely by phone. Longitudinal assessment of suicidal ideation and reasons for living will occur at eleven timepoints: baseline, after each of the six weekly treatment sessions, posttreatment (7 weeks), at 1-, 3-, and 6-month follow-up. The recruitment goal is 150 Veterans over a five-year period with 75 participants randomized to each treatment. Veterans must be 60 years or older, report suicide ideation, and meet diagnostic criteria for a depressive disorder, anxiety disorder, and/or posttraumatic stress disorder to be eligible. Veterans will be excluded and referred for other services if they have psychotic symptoms, bipolar disorder, severe OCD, or elevated symptoms indicative of borderline personality disorder; an alcohol/substance use disorder; severe or unstable medical conditions; recent head injury (past year) or history of a head injury with loss of consciousness for 24 or more hours; terminal illness; positive cognitive screen indicative of possible dementia; or if they are unable to participate in the study or follow-up sessions. Recruitment will occur through multiple strategies at VA, Vet centers, and in the community to ensure the feasibility of recruiting a total of 75 Veterans at each site. To meet this recruitment goal, the primary and secondary site will each enroll 2 to 3 Veterans per month. Fidelity ratings of audiotaped treatment sessions will be made by independent raters on 20% of sessions. Mixed effects modeling will be used to estimate the effect of treatment versus the control for the outcomes of suicidal ideation and reasons for living. Models will covary for demographics, medical and psychiatric comorbidity, and psychotropic use. For the primary aim, models will determine whether PST plus EUC is associated with a larger treatment effect compared with EUC only for suicidal ideation and reasons for living. Secondary aims will determine if baseline functional disability and executive dysfunction moderate treatment outcomes, and whether a change in these two variables from baseline to posttreatment are significantly associated with (mediate) change in suicidal ideation and reasons for living. The tertiary aims will use qualitative methods to assess Veteran satisfaction with the treatment and control including the types of problems with which treatment helped them, and suggestions for improving it for future Veterans. The current VA/DoD Clinical Practice Guidelines (CPGs) for suicide do not list treatment options specifically for older Veterans despite the majority of VHA patients being 55 years or older. Thus, evidence-based outcomes from the proposed work have potential to inform the CPG recommendations for using PST with Safety Planning and/or Safety Planning alone with older Veterans. Dissemination of the treatment could be supported by expanding existing VA training infrastructure in problem solving based interventions.

The purpose of this project is to evaluate the initiate a program of research to further evaluate its effectiveness across multiple outcomes, including: 1) proximal outcomes of the calls themselves including reduced caller distress, suicidality, and acceptance of a referral, 2) intermediate outcomes such as successful linkage and engagement in local mental healthcare, and 3) distal outcomes including reduced risk for suicide attempts and suicide.

The purpose of this project is to support efforts related to internal implementation and evaluation to evaluate the effects of the VCL regarding suicide prevention among Veterans. PEPReC will conduct quantitative analyses of VCL use and outcomes, impacts of VCL changes (e.g., expansion of a national suicide hotline [988] that will facilitate connection to VCL), and VCL staffing.

The purpose of this project is to use clinical data from chart reviews of VA medical records to identify risk and protective factors that differentiate Veterans who died by suicide in the six-month period following discharge from VA nursing homes from those who did not die by suicide, during the period from fiscal year 2002 to 2011.

The purpose of this research is to apply post-market surveillance and comparative effectiveness methods to secondary data to generate real world evidence (RWE) about the comparative safety of treatments and outcomes related to suicide. In response to HSR&D’s 2020 call for research on COVID-10, an amendment includes research on COVID-19.

The purpose of this study is to (1) develop the Insomnia Case Enumerator (ICE) using natural language process and machine learning to identify VHA patients with insomnia, and (2) to inform medication safety and prescribing by modeling the suicidal behavior of VHA patients by prescribed insomnia treatment.

The purpose of this study is to assess risk factors of suicide and premature mortality among Veterans who have recently separated from active military service.

The specific aims of this study are: (1) to investigate the relationship between trait measures of impulsivity and suicide attempt history in Veterans with bipolar disorder; (2) to investigate the neural circuitry underlying two models of state impulsivity and their relationship to suicide attempt history in Veterans with bipolar disorder; and (3) to identify which combination of impulsivity measures differentiates those with a history of suicide attempt from those without suicide attempts and healthy controls at a baseline timepoint and can be used to predict suicidal behavior longitudinally over 1 year.

The suicide rate among active duty service members and veterans increased substantially following the onset of post-9/11 conflicts in Iraq and Afghanistan1. Accordingly, veteran suicide prevention has been identified as a national healthcare and research priority2. Psychosocial interventions for suicide risk vary substantially in dose and resource allocation. A single therapy session designed to evaluate risk factors and provide support resources (e.g., Enhanced Crisis Response Plans [ECRP]3) has been shown to reduce risk for future suicide attempts. Other interventions consisting of 10-12 outpatient sessions following inpatient discharge (e.g., Brief Cognitive Behavioral Therapy for suicide prevention [BCBT]4) have been shown to reduce suicide attempts by 50-60% relative to treatment as usual. Although both forms of intervention have been shown to reduce risk, interventions that vary in dose and resource allocation have yet to be directly compared, leaving two critical gaps in our ability to intervene most effectively. First, the assumption that more time- and resource-intensive 10-12 session interventions translate to greater suicide risk reduction has yet to be demonstrated. Second, it may be that less resource intensive interventions are adequate for some individuals whereas others require more intensive care. To date, there is no evidence to guide what interventions are indicated for specific clinical presentations. Pharmacological and brain stimulation interventions for suicide risk are extremely limited. This is due, in part, to an incomplete understanding of the neurobiological mechanisms of suicide risk. Although numerous studies have examined cross-sectional neuroimaging correlates of current suicide ideation or compared individuals with and without history of a suicide attempt, to date no studies have examined a) neurobiological predictors of future suicide attempts in high-risk samples, b) how changes in neurobiological markers over time relate to changes in suicide risk, or c) theoretically and mechanistically relevant neuroimaging procedures in a prospective design. Cross-sectional research examining neuroimaging markers of past or current self-injurious thoughts and behaviors (SITBs) has identified dysfunction in regions associated with emotion regulation, inhibitory control, and decision-making5,6, namely in cognitive control networks (CCN). On the other hand, dysfunction has also been observed in regions associated with negative affect and rumination such as limbic (LN) and default mode (DMN) networks. Despite these cross-sectional findings, identification of neuroimaging predictors of future suicide attempts, and neural markers of successful suicide risk intervention outcomes represents a completely novel, critical step to guiding optimal targeting of neurobiologically-informed interventions and translating neuroimaging of suicide into practice. Whether these potential neuroimaging predictors are identifiable during resting state, or whether more suicide-relevant cognitive tasks are required, such as death-related bias or inhibitory control, remains an open yet critical question. The purpose of our proposed study is to compare two evidence-based suicide risk interventions that vary in dose in order to a) directly test if a more intensive intervention produces greater risk reduction, b) identify veterans for whom a more intensive intervention is indicated, and c) identify resting-state and task- based neurobiological markers of future suicide attempts and examine how changes in these markers relate to changes in suicide risk over time. We will recruit and evenly randomize 136 male and female veterans hospitalized for suicide risk to ECRP or BCBT. We will collect neuroimaging data immediately upon discharge, post-treatment, and 12-months post-discharge and assess SITBs out to 12-months post-discharge.

The toll of suicide goes way beyond the death of an individual. Those exposed (defined as knowing the person) to a suicide death are at elevated risk for mental illness, physical disorders, impaired social functioning, and fatal and nonfatal suicide behavior. Conclusions from the handful of studies that have examined this topic among Veterans are limited by distinct samples, limited sample sizes and other methodological issues. Additionally, the numbers of women and minority race/ethnicity service members and Veterans in these studies were too small to examine what are likely critical differences by sex and race.

Significance: This study will provide foundational information on an understudied risk factor for suicide in a cohort of Veterans at increased suicide risk post 9/11 Veterans within six years following military separation. It will provide information to inform suicide postvention strategies that target the population of suicide bereaved post-9/11 Veterans as well as those targeting women and American Indian/Alaskan Native (AI/AN) Veterans. Innovation and Impact: (1) Use of VA data to provide the most reliable prevalence estimates for suicide exposure among Veterans to date; (2) Oversampling of vulnerable but understudied populations -- Women and AI/AN Veterans; (3) inclusion of two comparison groups to elucidate the common and unique contribution of suicide exposure to health outcomes and patterns of VA service utilization; and (4) Assessment of the formal and informal supports Veterans receive for mental health problems associated with suicide using both survey and VA healthcare utilization data. Specific Aims: (1) Evaluate differences in the prevalence of posttraumatic stress disorder (PTSD), prolonged grief disorder (PGD), and in suicidal ideation, attempts and planning among Veterans exposed to suicide compared with those exposed to other causes of sudden death and with unexposed Veterans. We will also evaluate differences by sex and race. (2) Identify modifiable moderating factors for the association between suicide exposure and negative outcomes and modifiable moderating factors for the association between suicide or sudden death exposure and negative outcomes relative to those with neither exposure. (3) Describe treatment experiences, interests, reported suicide attempts, and patterns of VA service utilization among those exposed to a suicide death compared to Veterans exposed to other sudden deaths and to unexposed Veterans. (4) Contextualize quantitative findings through interviews with a purposive sample of Veterans exposed to suicide. The interviews will focus on modifiable factors at each level of the socio-ecological model of suicide prevention to better understand targets for intervention. Methodology: This explanatory sequential mixed methods study examines outcomes associated with suicide exposure in a nationally representative sample of post-9/11 Veterans enrolled in VA healthcare. We will collect data in three waves. Wave 1 will implement a national population probability sample using a brief survey to assess exposure history (suicide, other sudden death, neither) and exposure characteristics (e.g., time since exposure) among 11,400 Veteran respondents. Wave 2 will survey Wave 1 respondents, stratified by exposure history (suicide, sudden death, neither), to assess outcomes and variables of interest among 4,500 Veterans (1,500 respondents per exposure group). Wave 3 involves interviews with a purposive subsample of 32 Waves 2 survey responders who have been exposed to suicide but differ in outcomes. Quantitative analysis is the priority of the study; the qualitative component will contextualize the quantitative findings. Next Steps/ Implementation: This work will direct VA and the field towards an understanding of the most critical outcomes among veterans exposed to suicide, the mechanisms that may lead to deleterious outcomes, and lay a foundation for understanding the effective treatments and supports needed for Veterans who experience a suicide loss, including women and AI/AN Veterans.

The United States is currently experiencing a national epidemic of suicide for its youngest Service Members (SMs) still serving in the Department of Defense (DOD, 2019) and those that have already transitioned out of the military. For example, the rate of suicide for Veterans aged 18- 34 years old having more than doubled from approximately 22 suicide deaths per 100,000 in 2006 to 45 per 100,000 in 2016 (VA, 2018; VA 2019). It appears that a period of significant risk for these young Veterans is during their first year after separating from the military with recent estimates suggesting an increase of nearly 50% during this period (Kang et al., 2015; Shen, Cunha, & Williams, 2016). As a result of the troubling trends, two executive orders have been issued within the last two years calling for federal organizations to work closer with local, nonprofit and academia organizations to implement a public health approach to suicide prevention. Preventing suicide remains a top priority for the VA with similar sentiments of a public health perspective to suicide prevention being recently published National Strategy for Preventing Suicide (VA, 2018). In this strategy, the VA acknowledged that it must reach out to Servicemembers (SMs) and Veterans in the community before they experience an acute crisis (VA, 2018). Similarly, VISN 17 made a significant commitment to the Expiration Term of Service (ETS) Sponsorship program in order to engage SMs prior to them exiting the military. Preliminary analysis was conducted for a recent randomized control trial with post- 9/11 Veterans in New York City that received the support from ETS Sponsors with the results showing a moderate treatment effect for both reduced transition stressors and improved social support (Geraci, 2018). Aims. We propose a Hybrid Type 2 effectiveness-implementation trial to evaluate the expansion of ETS Sponsorship across six cities from FY 2020 to 2023 in Texas. Aim #1 will determine the effectiveness of the ETS sponsorship program, as evidenced by measures of transition stressors, social support, psychological distress, suicidal ideation and behaviors, and VA/non-VA service utilization. Aim #2 will determine the feasibility and potential utility of implementing the ETS Sponsorship program to six cities in Texas. SMs that transition to cities without an established ETS Sponsorship program will experience their transition from military to civilian life as usual (i.e., services available from the U.S. Army Soldier for Life-Transition Assistance Program). After cities have implemented the ETS Sponsorship program, transitioning SMs will have access to an ETS Sponsor in their city and warm handoffs to community services. Methods. We will use a stepped wedge design while using other cities as controls until they begin implementation. This design will allow us to extend implementation support to the maximal number of cities and enhance the formative evaluation (periodic reflections with key partners and SM interviews). The stepped wedge design also enables us to make efficient use of all data available for within-site and between-site comparisons. For the within-site comparison, cities will act as their own controls in a program evaluation that compares cities pre- versus post- implementation. The comparison examines cities as they cross-over from control to intervention states. The between-site comparison evaluates the intervention period for a city vs. all other intervention and control periods for all cities. Outcomes of interest are measured for all transitioning SMs at each city within the given intervention time period. We randomized at the city level and will use individual SMs as the unit of observation for primary quantitative outcome measures. Six cities will participate in the program evaluation, with two cities allocated to each of the three start dates or steps. Hierarchical models will be run in which SMs are nested within city analyzing the results of the pre-implementation and postimplementation assessments. Hierarchical random effects models examine within- and between-group change across time and by condition.

The VA is committed to reducing suicide in the U.S. Veteran population. Over 6,000 Veterans die from suicide each year, and this risk is particularly high following a psychiatric hospitalization. This may be due to problems with engagement in care and poor social connectedness. Although the VA has implemented tools to address Veteran suicide risk, suicide after psychiatric discharge remains an ongoing problem. This has highlighted the need to develop new interventions and approaches to post-discharge mental health care within the VA. In response, this project is a randomized control trial of an intervention an intervention called Prevention of suicide: Education, Awareness, Connection, and Engagement (PEACE). This intervention is comprised of two synergistic and promising components to prevent suicide: 1) a mobile mental health app, which aims to improve social connectedness after discharge; and 2) a manual-based intervention called the Veterans Affairs Brief Intervention and Contact Program (VA-BIC), which promotes engagement in care. The overall goal of this study is to determine if the PEACE intervention combined with standard discharge care reduces suicidal ideation as compared to a control group receiving only standard discharge care.

Objectives: This project aims to 1) Identify the effect of PEACE on suicidal ideation after psychiatric hospitalization, compared to standard care alone; 2) Identify the effect of PEACE on social connectedness and engagement in care after psychiatric hospitalization, compared to standard care alone; and 3) Compare the effect of PEACE on suicide attempts and suicide deaths after psychiatric hospitalization, compared to standard care alone.

These are the aims for FY24 (FY24 is year 2 of the project, building on the work done in FY23): Problem statement: There are pragmatic, ethical, and methodological challenges related to including individuals at high risk of suicide in research about suicide prevention in VA. Available resources reflect consensus about project-level ethical and safety protocols, but there is little to no information about: (a) the extent to which research regulatory bodies integrate these guidelines into their decision-making, (b) how researchers view the utility of these guidelines, and (c) which individual-level strategies help research staff prepare for, and have conversations with, research participants about suicide. Rural health impact: Safety protocols need to be modified to account for primarily telephone and video-based interactions with participants, as well as to reflect awareness of and attention to rural contexts. Activities: We will conduct a feasibility study to generate evidence about the acceptability of and demand for a tool that supports researchers’ preparedness to respond to acute suicide risk via telephone or video (FY23 final product). We will conduct think-aloud interviews with a sample of participants to gauge feasibility, then revise the tool, and finally conduct focus groups with a sub-sample of participants from clinical, operational, research, and community contexts to gauge how the tool facilitates conversation among different stakeholders in suicide prevention research. Anticipated outcomes and products: A refined tool will be shared with SPRINT, GROVE, our Community Veteran Service Officer (CVSO) partners, and our operational partners including the VISN 23 Mental Health-Suicide Prevention Program Manager. We will also publish our findings through VA CyberSeminars and manuscripts.

This Career Development Award Level 2 (CDA2) represents the candidate's effort to execute a pilot study of a novel neuromodulatory treatment for Veteran [social and occupational functioning], impulsivity and [suicidal ideation] following mild traumatic brain injury (mTBI). The candidate's first aim will examine the tolerability, safety and feasibility of frontal pole intermittent theta burst stimulation (iTBS) for Veterans with mild traumatic brain injury (mTBI), negative urgency impulsivity, [and suicidal ideation]. This is important because impulsivity, which is exhibited in up to 40% of individuals with TBI, is an independent risk factor for dying by suicide and is associated with poorer functional outcomes following TBI. Presently, there are no widely accepted treatment strategies for impulsivity, [suicidal ideation and social and occupational functional deficits] following TBI. The candidate's second aim is to determine the effects of frontal pole iTBS on social and community functioning, negative urgency impulsivity and [suicidal ideation]. This will allow the scientific community to better understand how frontal pole iTBS treatment impacts [social and community] functioning and mental health outcomes. Finally, the candidate aims to evaluate whether iTBS improves connectivity between the VMPFC and limbic system, using resting state functional connectivity MRI. Completing this aim will allow us to better understand how iTBS affects neural connectivity and whether these changes are related to functional and mental health outcomes. This research is critical as suicide is a major issue among Veterans within the VA system. Veterans are 22% more likely to die by suicide than civilians. Veterans with TBI are even more likely to die by suicide than those without TBI. It is important to create a treatment to prevent unnecessary Veteran deaths while helping Veterans feel empowered and functional within their communities. [Suicide and TBI are not unique to Veterans, however. Civilians with TBI are also more likely to die by suicide than those without. Thus, findings from this research could serve to improve neuropsychiatric care in the civilian sector, as well.] This project serves as a critical first step in allowing the candidate and her team to develop a biologically-informed treatment strategy for the many individuals who struggle with mTBI, [social and occupational functional deficits], impulsivity and [suicidal ideation]. Ultimately, the candidate's long-term career goal is to become an independent clinical researcher in the VA system with expertise in TBI, suicidality, neurostimulation and neuroimaging. As such, she will complete a careful training plan under the mentorship of a strong, multidisciplinary training team involving opportunities for networking with experts in fields relating to the above research, hands-on training in necessary research skills and coursework complementary to the research project. The planned research is significant, innovative, and impactful, as it will be the first pilot study of a new iTBS treatment paradigm, designed to improve Veteran lives and functional outcomes after mTBI. It will also strengthen the candidate's knowledge base and research skills, preparing her for an independent career in post-TBI rehabilitation research, with expertise in impulsivity, suicidality and neuromodulation.

This is a prospective study of treatment outcomes for patients newly diagnosed with major depression

This is a randomized, double-blind, placebo-controlled study of the investigational drug uridine as a treatment for suicidal ideation in veterans. The investigators hypothesize that the administration of a naturally occurring dietary supplement, uridine, will rapidly reduce suicidal ideation in veterans. The purpose of this study is to determine whether 4 weeks of uridine supplementation is an effective treatment for suicidal ideation in veterans, when compared to a group taking a placebo. In summary, while piloting a much-needed alternative to intravenous ketamine for suicidal veterans, this research also aims to participate in establishing the neurochemical biomarkers of suicidal ideation, and treatment response. To test the novel intervention uridine as a rapid-acting oral treatment for Veterans with SI since uridine has the potential to fill this role lies in the broad overlap in the brain mechanisms and neural effects shared by uridine, ketamine and the anti-suicidal drug lithium. This is a randomized, double-blind, placebo-controlled study of the investigational drug uridine as a treatment for suicidal ideation in veterans. The investigators hypothesize that the administration of a naturally occurring dietary supplement, uridine, will rapidly reduce suicidal ideation in veterans. The purpose of this study is to determine whether 4 weeks of uridine supplementation is an effective treatment for suicidal ideation in veterans, when compared to a group taking a placebo. This research addresses two critical unmet needs related to suicidal behavior among veterans: 1) The unmet need for a rapid-acting treatment for veterans who are experiencing suicidal thoughts; and 2) The unmet need for valid objective measurements, or biomarkers of veteran suicidality, to improve diagnosis and guide treatment development. Through pilot testing the novel anti-suicidal treatment uridine, while pairing it with brain scans performed before-and-after treatment, the goal of this study is to improve our understanding of suicidal ideation in the veteran population.

This is a time of unprecedented loneliness and social isolation. Loneliness in particular is a powerful predictor of suicidal ideation, suicide attempts, functional decline, and death. Loneliness can and should be addressed by health systems. Due to risk for loneliness and negative health outcomes, a group of particular concern is older adults with medical or psychiatric comorbidity who have limited treatment engagement. Caring Contacts is an intervention that can address loneliness and poor treatment engagement. However, it has only been evaluated in a narrow population of psychiatric patients and not examined amongst patients impacted by the COVID-19 pandemic or other disasters.

Significance: This project addresses VA's top clinical priority (suicide prevention), an overarching priority of the Office of Research and Development (clinical trials), and multiple Health Service Research and Development priority areas, including social determinants of health, aging, access to care, mental health, suicide prevention, and population/whole health. The impact of this project is very high because it will advance scientific understanding of key gaps related to the mechanisms and outcomes of Caring Contacts, while also evaluating a timely, pragmatic, low-cost, and scalable intervention for Veterans affected by lack of social connection and treatment engagement. If effective, it will have applicability as a response to treatment disengagement and future disasters. Innovation and Impact: We have taken an empirically-grounded suicide prevention intervention and adapted it for Veterans with poor treatment engagement in VA outpatient care. This study is innovative in testing an intervention responsive to the COVID-19 pandemic and its aftermath, and unique in using a health services intervention strategy to target loneliness. The intervention's peer support component is highly novel for its low resource demands and potential for scalability. Specific Aims: The overarching objective of this project is to evaluate "Crisis Caring Contacts" (CCC), an adaptation of Caring Contacts tailored to reduce loneliness in the context of the pandemic. To reach this objective we will achieve these aims: 1) Among older Veterans with poor treatment engagement, evaluate the effectiveness of Crisis Caring Contacts in decreasing loneliness, compared to enhanced usual care; 2) Evaluate the effect of Crisis Caring Contacts on other important outcomes, including treatment engagement and suicidal ideation; 3) Explore potential moderators of treatment response to Crisis Caring Contacts; and 4) Explore the effect of Crisis Caring Contacts on all-cause mortality and suicide attempts. Methodology: Our approach is to conduct a multisite, pragmatic randomized controlled trial of CCC. We will target Veterans age 60 and over with active psychiatric or medical diagnoses who have had limited treatment engagement in VA outpatient care. Those in the CCC treatment arm will be sent 10 postcards over 10 months by a Peer Support Specialist. Those in the enhanced usual care arm (control) will be sent non-personalized, general health resource information. We will examine self-report and administrative data outcomes over 24 months of follow-up. Next Steps/Implementation: We will collect pre-implementation data from our study sites and share this with our operational partner, the Office of Mental Health and Suicide Prevention (OMHSP). Crisis Caring Contacts is highly suited to future implementation due to its scalability, ease of creating an operational dashboard to identify Veterans who could receive the intervention, and ability to add study materials to an implementation toolkit for VA Caring Contacts interventions.

This Merit Award resubmission in response to the RFA CX-18-023 addresses one of the top VA priorities, suicide prevention. Recognizing those at the highest risk of suicidal behavior with an imminent need for acute medical intervention remains a fallible subjective decision based on known risk and protective factors. Unfortunately, the contribution of each of these risk factors is small. Thus, there is an urgent need to develop adequate algorithms to predict imminent suicide risk. The overall objective of this application is to test the value of intrinsic brain activity as a marker of acute suicidal behavior and examine potential clinical correlates. Our central hypothesis is that a neural pattern classifier based on resting state functional connectivity will identify acute risk for suicidal behavior, by discriminating recent suicide attempters from current suicidal ideators, in a reproducible and specific fashion. This application is the progression of our pilot work that used machine learning to show that neural pattern classification of resting state-fMRI data allowed a specific differentiation of recent suicidal attempters (within three days of the attempt) from patients currently endorsing suicidal ideation with 79% accuracy. We plan to test our central hypothesis by using resting state functional connectivity to discriminate depressed Veterans who recently attempted suicide (n=80) from depressed Veterans with suicidal ideation (n=80), and non-suicidal stress controls (n=40). We will build on our previous work, replicating the same strategy that resulted in a trained classifier in a larger independent and more heterogeneous sample, and test whether the addition of demographic, clinical, cognitive and biological variables associated with suicide may improve the classifier accuracy (AIM 1). We will examine the temporal specificity of our classifier testing its ability to discriminate: a) clinically stable suicide attempters: attempters rescanned 5-8 days later when symptom severity had subsided, from suicidal ideators, and b) depressed patients with and without lifetime history of suicide attempts. We will also scan a stress-control cohort of age-, sex-matched non-suicidal controls hospitalized in medical-surgical units and attempt to distinguish them from suicidal ideators (AIM 2). Exploratory AIM1 will be a step towards translation, we will examine resting state functional connectivity obtained in 1.5T and 3T scanners. In exploratory AIM2 we will attempt to identify a responsible mechanism by using regression analysis between the most discriminating connectivity pathways between recent attempters and ideators and suicide attempt intent and lethality. We aim to test the reproducibility and specificity of a neural pattern classifier to discriminate recent suicide attempters from current suicidal ideators as a proxy measure of acute suicide risk. This neural pattern classifier, directly based on the function of the ultimate agent of human behavior, has the potential to significantly inform on suicide risk assessment, using an already widely available technology.

This Merit proposal is part of a BLR&D Collaborative Merit Award for TBI (CTBI) proposal (RFP #BX-19- 006) involving three separate but integrated proposals that together investigate the mechanisms by which TBI enhances impulsivity and suicidal behavior in Veterans. The rationale for the collaborative project is to combine neurobiological mechanistic studies in animals with human imaging and biomarker analysis to understand the manner in which TBI influences impulsivity and suicidal behavior. The overarching hypothesis is that TBI enhances impulsivity, a risk factor for suicide particularly in response to stress, through inflammation and dysfunction of the serotonin system and frontal lobe circuitry. Recent research increasingly highlights mild traumatic brain injury (mTBI) as a risk factor for suicidal thoughts and behaviors, including death by suicide. A study by Co-I Brenner found that Veterans with mTBI died by suicide at 1.8 the rate of the general Veteran population. The elevated suicide risk in Veterans with TBI is also consistent with previous research in civilians. Nevertheless, the study of suicide among those with mTBI is limited and there exists minimal understanding of the mechanism underlying this enhanced suicide risk in mTBI. There is a growing appreciation of the role of dysfunction in the circuits and white matter tracts underlying decision making in individuals with mTBI and history of a suicide attempt. However, neuroimaging studies examining the intersection of suicidal behavior and mTBI are limited. Moreover, how impulsivity and mTBI influences the development of suicidal behavior is also unclear. This project aims to address this gap with a neuroimaging project examining facets of impulsivity in Veterans with mTBI and a suicide attempt history. The James J. Peters VA (JJPVA) site proposes to investigate in male and female OEF/OIF/OND Veterans (n=140), the relationship of cognitive and behavioral impulsivity using a 2 (mTBI+/-) x 2 (history of suicide attempt (SA)+/-) design approach. Specifically, we will be examining four groups of Veterans: mTBI+/ SA+, mTBI+/SA-, mTBI-/SA+ and mTBI-/SA-. This project complements the animal studies being conducted at the New Jersey VA site by utilizing the same paradigms in humans during fMRI: the Go/No-go (motor) and Delay discounting (cognitive) task to assess impulsivity in both animals and humans. A primary objective of this study is to characterize alterations in brain activity and functional connectivity related to motor and cognitive impulsivity during fMRI in our four groups of Veterans. The secondary objective is to examine the relationship between white matter integrity using diffusion tensor imaging (DTI), and dynamic causal modeling with data from our two behavioral tasks of impulsivity performed during fMRI, along with psychometrically-validated measures of impulsivity. The third objective will be to determine similarities and differences in impulsivity data from animal TBI models and humans. All Veterans will receive rigorous diagnostic assessments, measures of impulsivity, clinical assessments of suicidal behavior, and a MRI scan (including structural MRI, DTI, and fMRI while performing impulsivity tasks). Blood will also be obtained for biomarker analysis, conducted by the Indianapolis VA site. Identifying potential neurobiological biomarkers for heightened suicide risk in Veterans with mTBI is essential for developing targeted care. The proposed research is translational as similar parallel analyses will be performed in humans and animals for investigating common neuronal circuits activated by impulsivity and genomic biomarkers.

This Merit proposal is part of a BLR&D Collaborative Merit Award for TBI (CTBI) proposal (RFP #BX-19-006) involving three separate but integrated proposals that together investigate the mechanisms by which TBI enhances impulsivity and suicidal behavior in Veterans. The rationale for the collaborative project is to combine human biomarker analysis, with human imaging studies, and with neurobiological mechanistic studies in animals, to understand the manner in which TBI influences impulsivity and suicidal behavior. Preventing suicide is a major priority for the VA. The overarching hypothesis is that TBI enhances impulsivity, a risk factor for suicide, particularly in response to stress, through inflammation and dysfunction of the serotonin system and frontal lobe circuitry. At the Indianapolis VA (INDVA) site, in order first to test our overarching hypothesis, and second to gain a more comprehensive understanding, we propose to translationally integrate human studies of subjects with TBI and suicidality with animal model studies of TBI, using blood biomarkers as a bridge. This will be accomplished via the following Aims: Aim 1 is Human biomarker studies. Aim 1. 1. will focus on state aspects, by conducting transcriptomic analyses on blood samples collected in Indianapolis. We will have two groups: suicidality with TBI (n= 70) and suicidality without TBI (n= 70). We will not be conducting imaging studies, but rather use a longitudinal design, by testing the subjects first during an acute inpatient psychiatric hospitalization for suicidality (severe ideation, plan, attempt), and then 3-6 months later for a follow-up visit in a low suicidality state. We hypothesize that inflammatory and serotonin related transcripts will be decrease between acute inpatient and non-acute follow-up testing, but less so in suicidality with TBI compared to suicidality without TBI. Aim 1. 2. will focus on trait aspects, by conducting transcriptomic analyses on samples from the Bronx VA (JJPVA) (n=140). We hypothesize that inflammatory and serotonin related transcripts will be increased most in suicidality with TBI compared to suicidality without TBI, TBI without suicidality, and non-TBI, non- suicidality. Aim 2 is Animal model brain and blood biomarkers convergence studies. We will conduct transcriptomic analyses of brain and blood samples from the animal model studies (n= 160) at the New Jersey VA (VANJHCS), a more experimentally tractable way of studying TBI and impulsivity. We hypothesize that we will identify biomarkers that are co- directionally changed in brain and blood. Aim 3 is Translational convergence of human and animal model biomarker data, using Convergent Functional Genomics analyses. We hypothesize that the candidate state and trait biomarkers that track suicidality (ideation, attempts) related to TBI (TBI-S) in the human studies will cross- validate with the brain-blood biomarkers from the animal model studies. We will also test hypothesis driven a series of known biomarkers related to inflammation (IL6, IFNG), serotonin (5HT2A, SLC6A4), and TBI (UCH-L1, GFAP- FDA approved in 2018). Exploratory Aim 4 will focus on convergence of biomarkers and phenomic data (neurobehavioral testing, imaging). We hypothesize that we can link different biomarkers to different behavioral aspects in the same individual and across individuals, resulting in a better understanding of the pathophysiological links between TBI, impulsivity, and suicidality. We will use a PhenoChipping approach (Niculescu et al. 2006)6, that clusters phenomics and genomics data. The number of new traumatic brain injury (TBI) cases for U.S. Military forces has more than doubled in the last five years and will continue to grow. TBI is a risk factor for suicidality. Moreover, increased impulsivity is one of the most prevalent symptoms following TBI, and is itself a risk factor for suicide, depression and drug abuse. Thus, finding objective biomarkers of increased risk of suicide and understanding the mechanisms responsible for high impulsivity following TBI are key to severing the link between TBI and suicide.

This project identifies VA Suicide Prevention Team members’ successes, challenges and needs around rural Veterans’ suicide prevention, develops recommendations for supporting Suicide Prevention Teams’ outreach and engagement in rural areas, and plans for an intervention to support rural Veterans in FY 22.

This project intends to extract from clinical progress notes concepts that are central to the 3-step theory of suicide (3ST), that is hopelessness, psychological pain, connectedness, and capacity for suicide, and test their potential to improve the accuracy of VHA's suicide risk prediction models: REACHVET and STORM. We have the following three specific aims:1. Develop a suicide-specific ontology for machine recognition of the key concepts of 3ST (hopelessness, connectedness, psychological pain, capacity for suicide) in progress notes of clinical encounters with Veterans who attempted or died by suicide. 2. Extract information on the presence and intensity of hopelessness, connectedness, psychological pain, and capacity for suicide in clinical progress notes and describe change in these concepts in proximity of a suicide or suicide attempt. 3. Determine the predictive validity of hopelessness, connectedness, psychological pain, and capacity for suicide regarding Veteran suicide attempt and mortality.

This project seeks to obtain novel information critical to understanding suicide risk and prevention among Asian American and Pacific Islander Veterans. Multiple methods will be utilized, including analysis of suicide mortality data, geospatial analysis, key informant interviews, qualitative interviews with Asian American and Pacific Islander Veterans, and analysis of survey data. This information will be harnessed to adapt and pilot test brief suicide prevention resources and interventions (e.g., Safety Planning, Caring Contacts) for Asian American and Pacific Islander Veterans. When possible, findings will be disaggregated across groups to increase understanding regarding how risk for suicidal self-directed violence varies across groups and to ensure that suicide prevention recommendations, resources, and interventions acknowledge the substantial heterogeneity in Asian American and Pacific Islander populations and are culturally-sensitive.

This study aims to (1) develop a manual to simultaneously address suicide risk and the functional impact of chronic back pain, (2) assess the feasibility and acceptability of MBCT for suicide risk and chronic pain in a sample of Veterans experiencing suicidal ideation and chronic back pain, and (3) assess the variability and distribution of treatment outcomes Following a small one-arm trial to assess feasibility and acceptability, individuals with SUD reporting loneliness will be randomized to either an 8-session cognitive-behavioral therapy for loneliness (CBT-L) or CBT-SUD both delivered via telehealth. We will further assess feasibility and acceptability outcomes as well as loneliness, and substance use outcomes.

This study aims to examine patient characteristics associated with an opioid-related overdose among Veterans receiving VHA services; as a secondary aim, this study will develop improved statistical models for predicting risk for opioid-related outcomes among Veterans receiving VHA services.

This study has the following aims: Aim 1: To describe baseline knowledge of lethal means safety among VA employees. Aim 2: To determine if a course on lethal means safety is effective at increasing knowledge on the subject. Aim 3: To examine evaluations completed by VA employees who completed the lethal means safety training.

This study seeks to increase knowledge regarding suicidal self-directed violence and suicide prevention among survivors of military sexual trauma through a cross-sectional survey and qualitative interviews with active duty personnel and Veterans. Specific aims are to: (1) Identify periods of elevated risk for suicidal self-directed violence among military sexual trauma survivors, relative to critical life events (e.g., military separation); (2) Examine the roles of institutional betrayal, institutional courage, and stigma in suicidal ideation and attempt across the transition from active duty to veteran status; (3) Understand military sexual trauma survivors’ lived experiences and perspectives on the roles of institutional betrayal and courage and stigma in their suicidal self-directed violence experiences and explore how these can be addressed; (4) Explore how findings differ as a function of gender, sexual orientation, and active duty vs. veteran status.

This VA Career Development Award will ensure my expertise in VA healthcare implementation research and health equity through formal training and applications of my knowledge through small research studies. The research studies in this project develop and pilot methods to engage rural VA patients in selecting and tailoring implementation strategies to implement the Safety Planning Intervention, a suicide prevention intervention. Rural VA patients represent a marginalized group related to suicide and mental health care—they experience suicide disparities and lack of equitable access to mental health care. Therefore, methods identified and refined in this research may generalize to other marginalized VA patients and will innovate implementation science to increase health equity.

To conduct a fully powered randomized controlled trial evaluating the effect of adding a standard TMS course of treatment to Brief Cognitive Behavioral Therapy (BCBT) to reduce suicide behaviors in a sample of Veterans hospitalized for suicide behavior.

To develop automated, natural language processing (NLP) methods to determine which Veterans have access to firearms and which have substance use disorders. To compare NLP assessments of firearm access and substance use disorders to template-based evaluation of firearm access by human reviewers and ICD-10 coding of substance use disorders by human coders. To identify elements of lethal means safety counseling that may be detected in notes using NLP methods.

Veteran suicide is a public health crisis and a current priority across the Department of Veteran Affairs. According to the National Strategy for Preventing Veteran Suicide, 10.2 million Veteran do not receive VA benefits or services as compared to the 9.7 million that do receive at least one benefit or service (U.S. Department of Veteran Affairs, 2018). The discrepancy in accessing services is multi-faceted and complex but it is clearly an opportunity for research and intervention. Previous research indicates that one possible explanation for the discrepancy is related to negative beliefs or stigma as a barrier to treatment (Hoge et al., 2004; Stecker et al., 2007). This study aims to explore this discrepancy between Veterans at risk for suicide that access mental healthcare and those that do not by eliciting and identifying beliefs about suicide and help seeking. This study will explore beliefs about suicide and seeking help in a Veteran population. More importantly, future work will harness the findings to obtain additional funding to develop a measure of suicidal thoughts and behaviors and a brief intervention. Utilizing data directly from Veterans will allow for greater opportunities to build accurate theories, intervention, and prevention strategies that may help to save lives and close the gap between those that access services and those that do not.

Veteran suicide is a public health crisis and a current priority across the Department of Veteran Affairs. According to the National Strategy for Preventing Veteran Suicide, 10.2 million Veteran do not receive VA benefits or services as compared to the 9.7 million that do receive at least one benefit or service (U.S. Department of Veteran Affairs, 2018). The discrepancy in accessing services is multi-faceted and complex but it is clearly an opportunity for research and intervention. Previous research indicates that one possible explanation for the discrepancy is related to negative beliefs or stigma as a barrier to treatment (Hoge et al., 2004; Stecker et al., 2007). This study aims to explore this discrepancy between Veterans at risk for suicide that access mental healthcare and those that do not by eliciting and identifying beliefs about suicide and help seeking. This study will explore beliefs about suicide and seeking help in a Veteran population. More importantly, future work will harness the findings to obtain additional funding to develop a measure of suicidal thoughts and behaviors and a brief intervention. Utilizing data directly from Veterans will allow for greater opportunities to build accurate theories, intervention, and prevention strategies that may help to save lives and close the gap between those that access services and those that do not.

Veterans face a "deadly gap" during their first year of transition from military to civilian life with limited available psychiatric services and increased suicide risk factors. During this critical transition period, Veteran suicide rate is double that of active service members and the general Veteran population. An average of 20 Veterans die from suicide each day, but only 6 of the 20 use VA services. VA care engagement has been shown to mitigate suicide risk; therefore, promoting engagement during the "deadly gap" could be essential to suicide prevention. Transitioning Veterans require outreach and services to provide them with support in their access to VA healthcare, suicide prevention education, and skills to manage their transition effectively. This proposal would bridge this important healthcare gap using STEP-Home. STEP-Home is an evidence-based, transdiagnostic, video telehealth rehabilitation workshop to improve reintegration, social support, and functioning among Veterans with high clinical comorbidity. STEP-Home is non-clinical, cost-effective, and skills-focused to maximally engage Veterans not participating in treatment who may be resistant to traditional "mental health" diagnostically focused approaches. To date, STEP-Home has not been adapted for the unique needs of recently transitioning Veterans or augmented for suicide prevention. This proposal will adapt and refine STEP- Home specifically for recently transitioning Veterans and add suicide prevention content and skills to create STEP-Home-SP. The proposed pilot study is designed to support STEP-Home and suicide prevention content experts in their refinement and evaluation of STEP-Home-SP. We will utilize the VA/Department of Defense Identity Repository (VADIR) to recruit recently transitioned Veterans nationwide. In Aim 1, we will develop STEP-Home-SP by adapting the STEP-Home telehealth intervention to specifically target recently transitioned Veterans and augment the workshop to include suicide prevention. In Aim 2, we will conduct a two-arm proof- of-concept acceptability and feasibility randomized controlled trial (RCT) of STEP-Home-SP versus Enhanced Usual Care (EUC=current standard of care + educational packet on suicide risk and connection to VA care) in recently transitioned Veterans. Lastly, we will explore reintegration status, VA care initiation, and candidate outcomes for STEP-Home-SP relative to EUC to inform a future full-scale RCT. If successful, fostering social, vocational, and community connection; building emotion regulation and impulse control skills; facilitating safety planning; and providing education and access to VA care upstream should result in decreased suicide risk during this critical transition and beyond.

Veterans Health Administration (VHA) has long known that Veterans who have recently had a suicidal crisis such as those in acute psychiatric hospitalization are at increased risk for suicide. In response, VHA developed a suicide prevention strategy and enhanced usual care (EUC) for high-risk Veterans by adding care coordination, safety plans, and access to a 24-hour crisis hotline. There has also been a broad array of innovative suicide prevention trials across VHA. However, the only intervention that has shown promise in reducing risk for suicide attempts in Veterans is Safety Planning, that has already been implemented across VHA. Despite these efforts, suicide rates following such crises have plateaued and there has been no observable reduction in risk in this population, requiring the development and testing of additional strategies that complement these already implemented approaches. Research suggests that treatments to reduce suicidal behavior may need to focus on both the motivation to live and the motivation to die to obtain optimal effects. The PI developed a revised version of Motivational Interviewing to Address Suicidal Ideation (MI-SI-R) to help Veterans resolve ambivalence about living by increasing the motivation to live, that is delivered as one-to-two in-person sessions with a telephone booster session. In a preliminary randomized controlled trial (RCT) in psychiatrically hospitalized Veterans, MI-SI-R plus EUC was associated with 50% fewer suicide attempts and 41% lower likelihood of suicidal ideation compared to EUC alone. Furthermore, post-hoc analyses suggested that MI-SI-R had a stronger impact on suicide attempt risk among those with an attempt history, but a stronger impact on suicidal ideation among those without a suicide attempt history, which requires replication. Additional research is also needed to deepen our understanding of MI-SI-R and its hypothesized mechanistic model by examining its efficacy among patients with different psychiatric disorders and its putative motivational mechanisms. We are proposing an RCT comparing MI-SI-R plus EUC (MI-SI-R+EUC) to EUC alone in a sample of 470 high- risk Veterans with recent suicidal crises from three VHA Medical Centers, with "high-risk" defined as a suicide attempt within a month or suicidal ideation > 5 on the Beck Scale for Suicidal Ideation. Half (n = 235) will be randomized to MI-SI-R+EUC (three sessions in-person, via Video Connect, or telephone) and the remaining participants (n = 235) will receive EUC alone. All participants will be asked to complete telephone follow-up assessments at 3, 6, 9, and 12-months after randomization. This will allow us to determine the efficacy of MI-SI- R+EUC in reducing risk for suicide attempts (Aim 1) and reducing overall suicidal ideation (Aim 2) when compared to EUC alone. We will also explore the possibility that MI-SI-R+EUC has a differential impact among patients with different suicide attempt histories and different psychiatric disorders and investigate putative motivational mechanisms (Exploratory Aim 3). This study is significant because suicide prevention is a VHA priority and targets a population that is known to be at very high-risk with a brief intervention that has high potential for implementation. It is innovative because it tests a revised intervention that targets the motivation to live making it novel among interventions that have been tested in full-scale trials, explores potential conditions that may impact its efficacy, and examines hypothesized motivational mechanisms.

Veterans who call the Veteran Crisis Line (VCL) have very high suicide rates. In response, the VCL plans to implement a Caring Letters campaign for all identifiable Veteran VCL callers who call about themselves (rather than a friend/loved one; ~80,000 callers per year). Traditionally, in the Caring Letters intervention, a series of messages are sent to individuals to communicate that they are not forgotten, and that people care about them and are concerned for their well-being. The messages also serve as a reminder that help is available. Multiple randomized clinical trials support the efficacy of Caring Letters for reducing suicide and suicide attempt rates. The Joint Commission recently promoted Caring Letters, and the intervention is included in the VA/DoD suicide prevention Clinical Practice Guideline. The campaign for VCL callers faces some unique challenges, however, since there is no established VA provider to serve as the signatory. Therefore, we propose a partnered program evaluation between VCL and the proposed research team to evaluate Caring Letters in a new population. Specifically, the evaluation will test two models: (1) A modified approach to Caring Letters in which letters are sent from a VA provider the Veteran does not know, and (2) a culturally-sensitive peer-based approach to Caring Letters in which letters are sent from peer Veteran who works at the VCL. In Aim 1, we will evaluate the effects of Caring Letters on clinical outcomes and VA clinical utilization rates. In Aim 2, we will examine the effects of the two different Caring Letter signatories on the clinical effectiveness of the intervention. Aim 3 will examine facilitators and barriers to implementing the Caring Letters campaign. In Aim 4, we will conduct budget impact analyses of implementation from the VA perspective. This will be the largest evaluation of a Caring Letters intervention ever conducted, and it will provide direct and actionable data to leadership to evaluate the impacts of this major prevention campaign.

Veterans who disengage from Veterans Health Administration (VHA) care are at elevated risk of death by suicide. The most recent national Veteran suicide data report shows that rates among this group have continued to increase over time, despite rates having decreased among Veterans who remain engaged in VHA care. This suggests that continued engagement in VHA care may be protective against suicide. Little is known about what predicts disengagement from VHA care, limiting upstream prevention efforts for supporting care engagement. The proposed Suicide Prevention Research Impact Network (SPRINT) Planning Grant will focus on Veterans who disengage from care in order to identify and test strategies to retain or re-engage those who may be at high risk for suicide. We will accomplish the following aims: Aim 1) Identify predictors for disengagement from VHA care among Veterans at risk for suicide; Aim 2) Examine the feasibility of research recruitment and collect pilot data among Veterans at risk for suicide who have disengaged from VHA care. We will achieve Aim 1 by extracting and analyzing data from the VHA Corporate Data Warehouse identifying Veterans with a positive screen on the Columbia Suicide Severity Rating Scale. We will utilize mixed effects, multivariable logistic regression to evaluate demographics, clinical, and health utilization predictors of disengagement from care in this potentially high-risk group. For Aim 2, we will employ an opt-out mailing approach to recruit Veterans from the cohort identified in Aim 1 into a brief study to determine patterns of recruitment response and to pilot test a newly developed interview guide. Study findings will inform a future mixed-methods IIR focused on further understanding health care experiences among Veterans at risk for suicide who disengage from VHA care and developing tailored intervention strategies for preventing disengagement.

VISN1 CDA

We have developed an internet based manualized group intervention that builds a COVID-19 resiliency/action plan titled- “Project Life Force- COVID 19”. This is 9 sessions and each session focuses on a step of the “action plan” (similar idea as a suicide safety plan) with particular focus on teaching coping skills, mindfulness. Differentiating covid 19 anxiety from physical symptoms, how to secure food, better exercise, access mental and physical health care, recognize warning signs, stay positive, practice gratitude and maintain connection with people despite social distancing. Pilot project has VISN 2 MIRECC funding and is currently enrolling subjects.

We propose a randomized, controlled trial of a video- and telephone-based, brief insomnia treatment in Veterans who meet criteria for Insomnia Disorder and Posttraumatic Stress Disorder (PTSD) to accomplish the goal of improving psychosocial functioning. The primary outcome for the trial will be psychosocial functioning, with insomnia severity serving as the secondary outcome. Additional goals include assessing durability of treatment gains and evaluating whether suicidal ideation decreases after insomnia treatment. Eighty Veterans with Insomnia Disorder and PTSD will be randomly assigned to either Brief Behavioral Treatment for Insomnia (BBTI; one 60-minute and one 30-minute video encounter, and two 20-minute phone- based encounters) or a Progressive Muscle Relaxation Training control group (manualized relaxation training delivered by two video and two phone sessions, matched to the BBTI condition for therapist time). Prior to randomization, participants will complete clinician-administered, mental health diagnostic interviews at baseline (and post-treatment). Self-report measures of psychosocial functioning, insomnia severity, and other mental health symptoms will be completed at baseline (pre-treatment), mid-treatment, post-treatment, and at 6-month follow-up (BBTI treatment group only). Sleep parameters will be completed with a self-report sleep diary. One week of sleep parameters data will be collected at baseline and continuously to the post-treatment appointment (and at 6-month follow-up for the BBTI treatment group only). We also will explore whether participation in BBTI helps to decrease suicidal ideation, which often occurs in Veterans with PTSD and insomnia. Information on suicidal ideation will be collected through the Depressive Symptom Index: Suicidality Subscale (DSI-SS) and the Columbia Suicide Severity Rating Scale (C-SSRS), the latter which is used clinically in the VA to assess suicide risk. We will allow Veterans with current suicidal ideation into the study but will exclude Veterans with current suicidal intent or a plan. Veterans who have suicidal ideation, but no intent or plan will be assessed at baseline, mid-treatment, and post- treatment and will be clinically monitored if any risk issues should emerge during treatment. This trial will provide useful information regarding rehabilitative outcomes, and it will yield specific information that will allow us to better understand whether a brief behavioral insomnia treatment can assist with suicidal ideation, a highly concerning issue among Veterans.

With approximately 23% of recent conflict Veterans meeting criteria for Posttraumatic stress disorder (PTSD), it has been described as a “signature wound” of combat Veterans. PTSD has been identified as one of the few mental health diagnoses that differentiate suicidal ideators from attempters and individuals diagnosed with PTSD tend to be at a higher risk for suicide. One of the leading evidence based practices for PTSD is Cognitive Processing Therapy (CPT), which utilizes a cognitive-behavioral framework to process trauma. Although CPT is an efficacious treatment for PTSD and has demonstrated decreases in suicidal ideation within Veterans who are at low risk for suicide, treatment effects on suicidal ideation have yet to be examined within Veterans who are at high-risk for suicide. Since severe suicidal ideation is most effectively addressed through direct intervention, integration of direct interventions addressing PTSD and suicidal ideation will help providers safely and effectively address both conditions. This study aims to explore stakeholders’ perspectives on the integration of suicide prevention techniques into CPT. This study will complete interviews with Veterans (n = 12) who received CPT and clinicians (n = 12) who are CPT-certified. Utilizing data directly from stakeholders will allow for opportunities to explore the development integrated treatment that can simultaneously address suicidal ideation and trauma within a high-risk for suicide sample.