Window to Hope, a small group cognitive-behavioral intervention, significantly decreased hopelessness compared to waitlist control and when offered to the waitlist participants. Significant decreases in hopelessness were maintained at follow-up for those originally allocated to WtoH. Suicidal ideation decreased but not significantly less than control.  These findings replicate those of the previous civilian trial, validating the efficacy of WtoH for decreasing hopelessness among Veterans with moderate to severe TBI.

Among the U.S. military personnel who were injured while taking part in Operation Enduring Freedom and Operation Iraqi Freedom, between 10 and 20 percent suffered traumatic brain injuries, or TBIs. These are injuries caused by a sudden trauma to the brain, such as when a person’s head violently strikes an object or by the dramatic change in air pressure following explosions. Although the vast majority of these TBIs are classified as mild, substantial interest has been generated to study TBIs across the full spectrum of severity. Research has shown that Veterans with TBI are significantly more likely than other Veterans to die by suicide. Unfortunately, to this point there have been no studies of ways to make suicide less likely among Veterans with traumatic brain injury.

That is changing, however, thanks to a recent study in Australia and the work of researchers at the Denver VA and the University of Colorado School of Medicine. The research in Australia, carried out by Grahame Simpson and colleagues, showed that it was possible to reduce hopelessness among adults with severe TBI using a treatment program based on cognitive behavioral therapy. This result was intriguing to researchers interested in decreasing the risk of suicide because feelings of hopelessness are a strong predictor of who is likely to die by suicide, and studies have shown that reducing feelings of hopelessness can reduce the risk of suicide among various types of patients.

Thus the group of Colorado researchers, led by Lisa Brenner, has been collaborating with Simpson to see if a cognitive behavior approach similar to the one he pioneered in Australia might be able to reduce hopelessness among a group of U.S. Veterans suffering from lasting effects of moderate to severe traumatic brain injury. The project is called Window to Hope. In 2014 the group published a report in the journal Brain Injury describing their work so far.

The first step in that work, explained team member Adam Hoffberg, was to revise Simpson’s program to apply to U.S. Veterans instead of Australian civilians. To do that the team assembled a nine-member panel that included experts in various aspects of traumatic brain injury and mental health, plus a TBI survivor and a family member of a TBI survivor. The panel agreed unanimously on a number of changes to the manual describing the treatment program. Some were simple changes, such as inserting the U.S. food pyramid in place of its Australian counterpart. Others were more substantive, such as modifying the manual to include “tactical breathing,” a type of deep breathing that U.S. service members are taught to use, instead of the original breathing exercises designed for use by Australian civilians.

The next step was to test the implementation of the revised program to U.S. Veterans with TBI. In particular, the group tested for three things: feasibility, or whether VA clinicians could carry out the program in the context of a VA center; fidelity, or whether the clinicians could carry out the program in a way that was faithful to what Simpson had developed; and acceptability, or how well U.S. Veterans with TBI accepted, or responded to, the program. The pilot study was carried out on four different groups of Veterans, each group led by a different clinician, with a total of nine participants. Window to Hope pilot results were promising, Hoffberg said. The study showed that the revised program was indeed feasible in this context, acceptable to the Veterans, and could be delivered with fidelity by VA clinicians. Most encouraging were the comments from the Veterans enrolled in the study, several of whom reported that they found that the program did indeed help them build hope.

Window to Hope is now undergoing a much larger trial designed to test its efficacy rather than simply its implementation. Hoffberg and his colleagues have recruited nearly four dozen Veterans, each with moderate to severe traumatic brain injury and moderate to severe feelings of hopelessness. Over a period of six months, each Veteran will undergo the three-month Window to Hope program and three months of standard care, with half getting the Window to Hope treatment first and half getting the standard care first. The researchers will measure the Veterans on feelings of hopelessness, depression, and thoughts of suicide at the beginning, middle, and end of the six-month period and evaluate the efficacy of Window to Hope intervention. If the program proves as efficacious for U.S. Veterans as it was for Australian civilians, it will open the door to helping the large numbers of brain-injured Veterans in this country deal with their hopelessness and be less likely to end their own lives.