Testing the Use of VA Peer Specialists to Prevent Veteran Suicide

BACKGROUND: Suicide is a top priority for the VA, claiming about 6,000 Veterans each year. VA suicide services primarily focus on immediate response to increased suicide risk but lack a focus on recovery, conceptualized by VHA as an internal process of hope, healing, empowerment, and social reconnection. The lack of a recovery focus in suicide prevention is a gap in VHA care quality. VHA Peer Specialists (PSs)-Veterans with serious mental illness (SMI) who are trained to use their experience to help other Veterans with SMI as full-fledged employees (\~1,400 VA-wide)-could improve the quality of suicide prevention by making these services more recovery oriented. Based on multiple studies showing that PSs improve a range of outcomes for Veterans with SMI, the VA National Strategy for Preventing Veteran Suicide calls for the development of peer-to-peer services to help those at risk for suicide for their ability to "impart hope and motivation for achieving recovery; provide support for addressing specific stressors, and help foster a sense of meaning and purpose."

SIGNIFICANCE: Administrative data shows that VHA PSs are already working with Veterans at risk for suicide. If PREVAIL-VA is effective, it could greatly increase the delivery of evidence-based services Veterans at risk for suicide receive and enhance the services by VHA Peer Specialists.

INNOVATION: No study has tested a PS-delivered suicide prevention service in the VHA in a rigorous trial.

SPECIFIC AIMS: The proposed study is a Hybrid Type 1 randomized trial with two aims: Aim 1: Deliver PREVAIL-VA and compare recipients of PREVAIL-VA and Usual Care on suicide-related and recovery outcomes. Aim 2: Collect qualitative data on PREVAIL-VA helpfulness, and implementation barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR) and rapid qualitative analysis.

METHODS: This application proposes to test in two VA health systems-Pittsburgh and Maryland-a promising PS-based approach to helping VA patients with a high risk of suicide, called PREVAIL-VA. Adapted from a civilian version with VA PS and suicide stakeholder input, PREVAIL-VA (Peers for Valued Living) provides 12, one-on-one sessions over about three months between a PS and a Veteran that involve semi-structured conversations focused on hope, belongingness, and safety. Session context is flexible, driven by the needs of the individual and by the ILSM (Invite, Learn, Share, Motivate) structure that guides how PSs interact with those whom they work. A civilian pilot study was promising; preliminary findings of a larger civilian trial showed small improvements. Veterans with documented suicide risk at each site (n=153) will be randomized to PREVAIL-VA or Usual Care (total N=306). Each site will have two trained PSs, who will each deliver PREVAIL-VA to \~40 Veterans over \~3 years (\~4 Veterans at any one time). PSs will be trained and receive an hour of group supervision weekly by the PREVAIL-VA developer and licensed psychologists, who will also be available for emergencies. Sessions will be taped and 15% rated for fidelity on standardized measures. Each Veteran will be assessed at baseline, post-intervention, and six months post-intervention on the primary outcome of suicide risk with additional primary outcomes focusing on recovery domains such as self-rated community integration; sense of hope, meaning, and purpose. Secondary outcomes will include suicide attempts, depression, belonging, and acute care visits for suicide-related reasons. The primary analytic strategy will be a generalized mixed-effect model approach including intervention group, time, and time by group interaction terms. Relevant covariates will include site, fidelity ratings, treatment attendance, VA service use, and demographic variables. At each site, all PSs and a subset of PREVAIL-VA Veterans, VHA clinicians whose patients received PREVAIL-VA, and clinical leaders will participate in qualitative data collection (periodic reflection, interview, focus group) about helpfulness of PREVAIL-VA and relevant CFIR-based implementation factors that could inform its future adoption. Qualitative data will be analyzed with a 'rapid analysis' approach.

NEXT STEPS/Implementation: If effective, we will develop an implementation toolkit and work with partners to teach PREVAIL-VA to all PSs.

• Columbia-Suicide Severity Rating Scale (C-SSRS) [Time frame: Baseline, 3 months, 6 months]
• Quick Inventory of Depressive Symptoms (QIDS) [Time frame: Baseline, 3 months, 6 months]
• Sheehan Disability Scale (SDS) [Time frame: Baseline, 3 months, 6 months]
• Interpersonal Needs Questionnaire (INQ) [Time frame: Baseline, 3 months, 6 months]
• Columbia-Suicide Severity Rating Scale (C-SSRS) [Time frame: Baseline, 3 months, 6 months]
• Suicide Cognitions Scale (SCS) [Time frame: Baseline, 3 months, 6 months]
• Herth Hope Index (HHI) [Time frame: Baseline, 3 months, 6 months]