Motivational Interviewing to Address Suicidal Ideation: A Randomized Controlled Trial with Suicidal Veterans

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.

Grant Number: 5I01CX002359-04
NIH Institute/Center: VA
Principal Investigator: PETER BRITTON