Post Admission Cognitive Therapy (PACT) for the Inpatient Treatment of Military Personnel With Suicidal Behaviors

• Repeat Suicide Attempts [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: Yes ]
  Repeat suicide attempts will be assessed using the Columbia Suicide Severity Rating Scale (C-SSRS), which assesses for number of subsequent suicide attempts.
  
  

• Depression [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: No ]
  The Beck Depression Inventory-II (BDI-II) will be used to assess for symptoms of depression.
  
  
• Hopelessness [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: No ]
  The Beck Hopelessness Scale (BHS) will be used to assess for levels of hopelessness.
  
  
• Suicide Ideation [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: No ]
  The Scale for Suicide Ideation (SSI) will be administered to assess for suicide-related thoughts (ideation), as well as the frequency, intensity, and specificity of these thoughts.
  
  
• Post-Traumatic Stress Symptoms [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: No ]
  The Clinician Assessment of PTSD Scale (CAPS) and the PTSD Checklist (PCL) will be administered to assess for post-traumatic stress symptoms.
  
  
• Acceptability of Treatment [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: No ]
  Acceptability of treatment will be assessed by using Barriers to Care Items.
  
  
• Repeat Psychiatric Hospitalizations [ Time Frame: 1, 3, 6, and 12 months ] [ Designated as safety issue: No ]
  Subsequent psychiatric hospitalizations will be assessed for using the Cornell Services Index (CSI), as well as by accessing the Defense Medical Surveillance System (DMSS), which contains electronic medical records of all military personnel (permission to access participants' DMSS records is given at time of consent).
  
  

Background: Suicide remains a serious national public health problem and has become a leading cause of death in the United States military. To date, there is no evidence-based civilian or military inpatient interventions aimed at the reduction of suicide behavior. Our proposal addresses this important gap and aims to evaluate an innovative suicide intervention, Post Admission Cognitive Therapy (PACT). Left untreated, severe suicide ideation and/or suicide attempts that require psychiatric hospitalization may place an individual at a lifetime risk for increased psychopathology, subsequent suicide behavior, and death.

Objective: The broad objective is to implement and empirically evaluate the efficacy of a cognitive behavioral intervention program, titled Post Admission Cognitive Therapy (PACT), for military service members admitted for inpatient care due to severe suicide ideation (with lifetime history of suicide attempt) and/or a recent suicide attempt.

Specific Aims: To evaluate the efficacy of PACT plus Enhanced Usual Care (EUC) versus EUC for the prevention of suicide in psychiatrically hospitalized military personnel at follow-up (1, 3, 6, and 12-month) on (1) incidence of repeat suicide attempt(s) and number of days until a repeat suicide attempt (primary outcomes), and (2) psychiatric symptoms (depression, trauma, sleep, suicide ideation), repeat number of psychiatric hospitalization(s), hope for one's future, and acceptability of treatment (as measured by time to linkage to specialty care, attitudes toward seeking help for mental health issues, and subsequent mental health service utilization) (secondary outcomes). The investigators expect that adults in the PACT+EUC (experimental) condition compared to those in the EUC (control) condition will show favorable outcomes on both primary and secondary measures.

Study Design: The research design is a multi-site, single-blind, randomized controlled trial (RCT). A total of 218 individuals who are over the age of 18, able to communicate in English and willing to provide informed consent will be recruited from the inpatient psychiatric units at the Walter Reed Army Medical Center and the Naval Medical Center Portsmouth. Participants will be randomized into one of two conditions: (1) [Post Admission Cognitive Therapy (PACT) + Enhanced Usual Care (EUC)] or (2) Enhanced Usual Care (EUC). Individuals randomized into PACT+EUC will participate in the study assessments, receive six 60-90 minute individual face-to-face PACT psychotherapy sessions provided during their inpatient stay, up to a maximum of four 30-minute phone PACT booster sessions during the 3 months post hospital discharge, and case management services for 12 months. Individuals randomized into the control condition (EUC) will not receive the study intervention; they will receive the usual care provided in the inpatient setting, participate in study assessments, and receive case management services for 12 months. Patients in both conditions will be assessed on the dependent measures at baseline and at 1-, 3-, 6-, and 12-month follow-up intervals.

Relevance: Delivering a brief and possibly potent psychotherapeutic intervention during a psychiatric inpatient hospitalization followed by an aftercare component aims to directly target individuals at high risk for future suicide behavior, specifically young, psychiatrically hospitalized adults under the direct stress of a military career. The development and empirical validation of an inpatient cognitive behavioral treatment is a significant endeavor in our national as well as Department of Defense (DoD) suicide prevention efforts. If Post Admission Cognitive Therapy is found to be efficacious, the intervention can be subsequently disseminated to inpatient settings as the standard of care for military personnel and beneficiaries admitted for suicide-related events.