Effects of a Targeted Web-Based Suicide Prevention Intervention on Suicidal Ideation and Self-Directed Violence: A Randomized Controlled Trial in Veterans

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.

Grant Number: 5IK2CX002448-03
NIH Institute/Center: VA
Principal Investigator: Joseph Boffa