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UW study of text messages to prevent suicides in military shows intriguing results

Carol Cruzan Morton

“Good to meet you yesterday.” “Hope things are going well and you’re having a good week.” “Hey – Just wanted to say hello.”

With these simple text messages at scheduled times, researchers at University of Washington hoped to prevent suicides in soldiers and Marines by reaching out about once a month for a year. If successful, the inexpensive tactic could be deployed on top of the usual mental health care to address a troubling increase in suicide rates in active-duty military and veterans.

Did it work? It depends whom you ask.

“Caring contacts by text message helped to prevent suicide attempts and suicidal ideation among active duty soldiers and Marines,” says Amanda Kerbrat, co-author of a new study testing its effectiveness in more than 600 military service members, nearly half of whom had previously attempted suicide. The study was published Wednesday in the journal JAMA Psychiatry.

The high rate of suicide among veterans and active military has been an ongoing concern. In Oregon, one in five suicides occurs among veterans, according to Oregon Health Authority figures.

Charles Hoge, a psychiatrist at the Walter Reed Army Institute of Research, said the trial was “a very important part of larger effort to fund and run large scale randomized controlled trials focused on potentially preventive intervention.”

However, he said, “This particular study of this particular intervention showed it’s not very effective in this population.” The study showed no significant differences in the two primary outcomes, current suicidal thoughts and hospitalizations to prevent suicides.

The mixed interpretations of the study illustrate both the urgency and difficulty in evaluating ways to prevent suicides. Suicides have increased in every state except Nevada from 1999 to 2016, according to the U.S. Centers for Disease Control. In Oregon, where more than two people kill themselves a day, suicides have been higher than the national average for decades and are the eighth leading cause of death.

Nationally, suicides among armed forces are now similar to the general population, after decades of being lower, Hoge wrote in an editorial in the same journal.

The new study tested an idea from the 1970s that has captured the attention of researchers, advocacy groups and policy makers—including those in Oregon. Now known as “caring contacts,” it was the first psychological intervention shown to reduce suicide death rates in a randomized clinical trial, the most unbiased way to test treatments in people.

In the original research, San Francisco psychiatrist Jerome Motto was concerned about high-risk patients hospitalized for being suicidal or depressed who refused treatment when they were discharged. Motto divided the “no-treatment” people into two groups. One group received no contact, while the other group received short letters by U.S. mail every few months for five years. For the first two years, the number of suicides in the no-contact group was twice that of the contact group.

More than half of the people in Motto’s study were women, with an average age of 34. Since then, at least a dozen studies have tested this idea of repeated follow-up contacts in other people around the world. One other study using in-person visits and telephone calls in five countries showed the follow-ups reduced suicide deaths. The other studies showed mixed results, says David Luxton, a clinical psychologist at University of Washington School of Medicine.

“People used to ask me, if this works, why are we not doing it already,” says Luxton, who was a consultant on the new study and recently finished a similar study in 1300 active military and veterans with similar mixed results, which has been submitted to a journal. ”My answer is that we are doing the research now to see if this works in modern times and with modern technology.”

In the new study, Kerbrat and her colleagues recruited 650 U.S. Army soldiers and Marines at three bases in North Carolina and California. Most were men in the mid-20s with previous or current suicidal thoughts or attempts. They could volunteer for the study or be referred by a clinician.

The team, led by clinical psychologist Kate Comtois, had originally proposed measuring how caring contacts by text affected suicidal thoughts at the end of the study, as well as hospitalization to prevent suicides. Those are the outcomes that showed no significant improvement.

But in follow-up interviews, study participants reported suicide attempts for which they did not seek medical care. By that count, fewer in the caring contacts group (9 percent or 21 people) attempted suicide over the study year, compared to 15 percent or 34 people in standard care alone.

“These results are not blowing the roof off anything, but they are statistically significant and clinically significant,” Kerbrat says. Importantly, “it’s unlikely to harm people,” she says. “It’s up to decision makers about whether or not they think there is sufficient evidence to do ahead and do an intervention like this.”

Kerbrat speculates that results could have been affected by including people at lower risk of suicide, rather than the most severe risk. A different texting protocol may work better, she says. Study participants were allowed to respond to the text messages, such as mentioning they were going to try to return to school after the military. The research team texters could not reply outside of a strict protocol. By the time they were able to wish a person good luck with school in the next scheduled text, those plans had fallen through, Kerblat says. The protocol was revised half way through the study to allow one more encouraging reply, and outcomes were stronger in this group.

Both Kerbrat and Luxton are analyzing their data to learn if caring contacts is more effective with certain people or at certain times, such as in people at highest suicide risk or at the transition between hospitalization and outpatient care.

“It is frustrating as a researcher and a clinician,” Luxton says about the difficulty in acquiring evidence for suicide prevention.

As for caring contacts, “I still recommend it, even though my study doesn’t show a sweeping reduction in mortality,” he says. “In my opinion, we have enough data that we should be doing it. This is about the health care system following up with someone they’ve encountered. By taking an active role in staying connected, they can help that person get into outpatient care. I see high value in that.”

For those who want to implement some version of caring contacts, Luxton is preparing a manual and Kerbrat and her colleagues are working on a tool kit.

In Oregon, caring contacts is written into a new state law that took effect December 1. For a person who was discharged from the hospital for mental health treatment or released by the emergency department after a behavioral health crisis, a caring contact within 48 hours to transition a person to outpatient services or community-based care, says OHA spokesperson Saerom England.

It’s too soon to know whether the caring contact mandate has had any effect in Oregon. Lines For Life, a regional nonprofit that runs crises phone and text hotlines, has contracts with several Oregon hospitals to provide the legislated contacts, is getting 5-15 confidential referrals a day, says Stephen Canova, followup services coordinator at Lines For Life.

“We set up calls to reach out to a person multiple times after their discharge, at 24, 48 and 72 hours,” he says. “That’s just to make sure we get them. If we reach them in 24 hours, and they’re doing well, have good support, have an appointment with a counselor in the next seven days, and feeling well supported, then we won’t call again.”

On day 8, they call to see how the appointment went. “The hope is to increase engagement in mental health services,” he says.

But caring contact calls seem to have been helpful to crisis hotline callers who agreed to the follow up, says Lines For Life COO David Westbrook. Two years ago, an analysis of those follow-up calls by Columbia University researchers found evidence that followup calls can reduced the risk of perceived suicidal behavior.

National Suicide Prevention Lifeline 800-273-TALK (8255) is a free, 24/7 service that can provide suicidal persons or those around them with support, information and resources.

Original Article