ICRC-S Community of Practice. September 2016

Transcription

1 ICRC-S Community of Practice September 2016

2 Technical Tips Audio is broadcast through computer speakers If you experience audio issues, dial (855) and mute computer speakers Download resources from File Share pod You are muted ] Use the chat to ask questions at any time This session is being recorded suicideprevention-icrc-s.org 2

3 Speakers Elizabeth Karras, PhD Todd M. Bishop, PhD suicideprevention-icrc-s.org 3

4 Opportunities for the Strategic Use of Suicide Prevention Communications Elizabeth Karras, PhD Center of Excellence for Suicide Prevention Mental Health Services Department of Veterans Affairs

5 Overview Defining communication Influencing health behaviors The promotion of mental health and suicide prevention Public messaging in practice: An example from the Dept. of Veterans Affairs Suicide Risk Factors: Access to Lethal Means Public Messaging to Promote Firearm Safety VA Gun Safety Video 5

6 What is Communication? Communication is a broad discipline & studied across contexts (Rogers & Storey, 1987) Health communication includes the study and use of communication strategies to inform and influence individual decisions that enhance health (CDC Gateway to Health Communication & Social Marketing Practice ) Intentional persuasive effort to generate specific outcomes/effects Target relatively large populations Conducted within a specific period of time Use organized set of communication activities (e.g., messages, outreach) Can include elements of social marketing (4 Ps ) that seek to increase the acceptability of a social idea or practice among targeted groups (maximize group response to messages) Regularly used to address public health issues 6

7 Potential Reach of Public Communication Interventions Evidence that health campaigns can have small-moderate effects on health behavior (Snyder et al, 2004; Noar, 2006; Wakefield, Loken & Hornik, 2010) wide reach translates into population-level impact Viewable impressions potential number of views/exposures to campaign materials by audience Common marketing metric for quantifying message reach (visible for a few seconds) 1 million impressions for campaign over time (across implementation areas/media) % Audience # 10k 20k 30k 40k 50k... 7

8 Variables that Influence Behavior Change Theory of Planned Behavior; Azjen (1985) 9 8

9 Communication for Suicide Prevention & Mental Health Promotion Identified as promising intervention to promote/support suicide prevention efforts in U.S. National Strategy for Suicide Prevention Implementation of research-informed communication efforts Some guidance in development of safe public messaging provided by National Action Alliance Increasingly popular in public health approaches to suicide prevention, yet little published work on evaluation & results Campaigns require careful design, implementation, & evaluation

10 Public messaging in practice: VA gun safety PSA 10

11 Firearm Suicide & Veteran Status Completed Male Veteran Suicide Completed Female Veteran Suicide Other 5% Suffocation Poisoning 17% 10% Suffocation 20% Other 7% Poisoning 32% Firearm 68% Firearm 41% Suicide Data Report (2016), VA Office of Suicide Prevention ( 11

12 Addressing Antecedents: Public Messaging to Promote Firearm Safety Institutional Diffusion Campaign Activity Exposure to PSA Social Diffusion Message Response Persuasive? 12 Theory of Planned Behavior; Azjen (1985) 9

13 VA Messaging: Gun Safety Matters VA developed PSA to promote firearm safety beliefs and practices Content was tailored for Veterans and their families and informed by consideration of military culture Developed in collaboration with multiple stakeholders The National Shooting Sports Foundation (NSSF) Harvard Injury Control Research Center VA Suicide Prevention Office 13

14 Study Aims: Can messaging improve firearm safety outcomes among Veterans? Primary Aim: Describe shifts in antecedents pre/post exposure among sample Exploratory Aim: Examine intentions/behaviors pre/post exposure among gun owners 14

15 Spectrum of Attitude Change NEUTRAL/ UNCERTAIN/ -- INDIFFERENT + RESISTANT SUPPORTIVE 15

16 Study Design & Methods OVERVIEW: Online RCT to assess changes in attitudes, perceptions, intentions and behaviors related to firearm safety among Veterans Multiple conditions each exposed to messages 3 times over 4 weeks Assessed at Baseline & Exit; Data collected from Dec 2015 to Jan 2016 Report exposure to gun safety PSA SAMPLE: Survey data collected from a national random sample of Veterans implemented by GfK KnowledgePanel (large-scale online panel based on a representative sample of the U.S. population) Broad inclusion criteria: Veterans 18+ living in U.S. (non-institutionalized) MEASURES (self-reported): (1) demographics; (2) injury beliefs and attitudes towards safety practices; (3) perceptions of safe storage practices; (4) safe storage intentions/practices ANALYSIS: Descriptive statistics reported (SAS 9.4); Restricted to complete cases (respondents with pre/post-exposure data) Data weighted following benchmark distributions of the adult U.S. Veteran population from the August 2014 Current Population Survey (CPS) 16

17 Demographic Characteristics (n=115) Variable % (n) Age Group %(11) %(11) %(28) %(65) Sex (Male) 90.6%(104) Race/Ethnicity White 82.2%(94) Black 11.2%(13) Other (non-hispanic) 1.0%(1) Hispanic 4.9%(6) Marital Status (married) 72.3%(83) Region Northeast 15.0%(17) Midwest 22.7%(26) South 40.2%(46) West 22.1%(26) Mental Health Status (excellent) 51.5%(59) VHA use in past 12 months 14.8%(17) Household Firearm Access 44.4%(51) Stored loaded and/or unlocked 84.0% (43) of those with access 17

18 Susceptibility to Injury: Perceptions of Community Risk (n=115) FIREARM INJURY SUICIDE

19 Injury Prevention Strategies: Perceptions of Efficacy of Firearm Safety Practices (n=115) FIREARMS STORED UNLOADED FIREARMS STORED LOCKED

20 Attitudes towards Safe Firearm Storage: Decreases Suicide Risk (n=115)

21 Attitudes towards Safe Firearm Storage: Offsite Storage for Suicidal Individuals (n=115)

22 Attitudes towards Safe Firearm Storage: Lethal Means Counseling (n=115)

23 Intentions: Firearm Access & Unsafe Storage (n= 39) Obtain Gun Safety Lock in next month

24 Behaviors: Safe Storage Practices (n=51) 24

25 Discussion Public messaging can serve as a viable method to produce broad shifts in health determinants including outcomes related to firearm safety Improvements in proximal outcomes identified with limited exposure to PSA Consider targeting specific determinants with messaging to increase likelihood of the adoption of safe storage beliefs and practices Continued exposure may be needed to motivate sustained changes Continue shifts beyond uncertainty/neutral beliefs Limited changes in distal outcomes including intentions/behavior Next steps to diffuse messaging themes include community-based partnerships 25

26 References 1. Rogers, E. M., & Storey, J. D. (1987). Communication campaigns. In C. Berger & S. Chaffee (Eds.), Handbook of communication science (pp ). Newbury Park, CA: Sage. 2. Centers for Disease Control and Prevention.Gateway to Health Communication and Social Marketing. Retrieved from 3. Snyder LB, Hamilton MA, Mitchell EW, Kiwanuka-Tondo J, Fleming-Milici F, Proctor D. (2004). A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. J Heath Commun, 9, Noar SM. (2006). A 10-year retrospective of research in health mass media campaigns: Where do we go from here? J Health Commun,11(1), Wakefield, M.A., Loken, B., & Hornik, R.C. (2010). Use of mass media campaigns to change health behavior. Lancet, 376, Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckman (Eds.), Actioncontrol: From cognition to behavior (pp ). Heidelberg: Springer. 26

27 Resources Gun Safety PSA Veterans Crisis Line Make the Connection 27

28 Sleep Disturbance and Its Relationship to Suicidal Thought and Behavior: A Cross Cutting Risk Factor and Low Stigma Opportunity for Intervention Todd M. Bishop, PhD VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY Department of Psychiatry, University of Rochester Medical Center, Rochester, NY

29 Acknowledgements, Disclaimers, & Conflicts of Interest Support: Dr. Bishop is supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Canandaigua VA Medical Center, and the VA VISN 2 Center of Excellence for Suicide Prevention. Acknowledgments: I would like to thank Dr. Wilfred Pigeon for generously allowing me to present data from his HSR&D pilot study: VA HSRD I21 HX Conflicts of Interest: None to report Disclaimer: The views or opinions expressed in this talk do not represent those of the Department of Veterans Affairs or the United States Government.

30 Sleep: Why Worry? Prevalence Sleep problems are experienced by 30% of the general population, with 5-10% likely meeting criteria for insomnia disorder Rates among individuals with mental health disorders (e.g., depression, anxiety, PTSD, etc.) range from 50-80% Persistence Sleep problems do not tend to resolve spontaneously or by treating comorbidities 50-70% of individuals that experience acute insomnia in a given year will go on to develop chronic insomnia Perniciousness Exacerbate and can even contribute to the development of comorbidities (e.g. depression; cardiovascular disease; diabetes) Treatable Effective treatments exist for sleep apnea, nightmares, and insomnia Matteson-Rusby (2010) Why treat insomnia? Primary Care Companion J Clinical Psychiatry, 12(1): e1-e9.

31 Sleep: A Gateway to Treatment Relieving a health problem that impacts functioning Improving cooccurring medical & psychiatric disorders Diminishing or preventing negative health consequences Decreased stigma and resistance to pursuing needed mental health services Does improving sleep alter the path to suicide?

32 Sleep and Suicidal Ideation in 654 Veterans Assessments performed by the VA Behavioral Telehealth Center Multiple Regression controlling for age, gender, etoh, depression Severity of Sleep Disturbance Severity of Suicidality Percent (%) of Sample p <.01 None Little Mod. Alot Extreme None Low Mod. Mod-Hi High Very Hi Bishop, Pigeon, & Possemato (2013) 32

33 Sleep Preceding Suicide in 381 Veterans Sleep Disturbance (Avg = 75 Days) No Sleep Disturbance (Avg = 174 Days) 33 Pigeon, et al (2012), Am J Public Health.

34 Why Focus on Sleep in Suicide Prevention? There is growing evidence that sleep disturbance is associated with suicidal thought and behavior: Bernert, R. A., Joiner, T. E., Cukrowicz, K. C., Schmidt, N. B., & Krakow, B. (2005). Suicidality and sleep disturbances. SLEEP, 28(9) Bernert, R. A., & Joiner, T. E. (2007). Sleep disturbances and suicide risk: a review of the literature. Neuropsychiatric Disease and Treatment, 3(6) Malik, S., Kanwar, A., Sim, L. A., Prokop, L. J., Wang, Z., Benkhadra, K., & Murad, M. H. (2014). The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Systematic Reviews, 3(1). Pigeon W.R., Pinquart M., Conner K. (2012). Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. Journal of Clinical Psychiatry, 73(9). 34

35 Why Focus on Sleep in Suicide Prevention? Sleep & Suicide Meta-Analysis Risk Associated with Any Sleep Disturbance Risk Ratio (95% CI) Ideation (k=33) Attem pt (k=15) Suicide (k=8) All (k=56) Ideation (k=18) Attem pt (k=8) Suicide (k=5) All (k=31) 35 Pigeon, Pinquart & Conner (2012), J Clin Psychiatry.

36 Why Focus on Sleep in Suicide Prevention? Highly efficacious interventions exist for most sleep disorders These interventions can be delivered across settings and are not exclusive to specialty mental health Patients are open to engaging in these interventions Pharmacologic FDA Approved Hypnotic Medications Off-label use of medications with sedating side effects OTC sleep aids Nonpharmacologic Several behavioral, cognitive, and relaxation approaches Cognitive-Behavioral Therapy for Insomnia (CBT-I)

37 Cognitive-Behavioral Therapy for Insomnia (CBT-I) Multi-component intervention Standard delivery in 5-8 individual or group session; sometimes shorter Requires therapist fidelity and patient adherence Is now the recommended first line treatment for insomnia 37

38 CBT-I Treatment Components & Targets Behavioral Sleep Restriction Stimulus Control Relaxation Therapy Excessive time in bed Irregular sleep schedules Sleep incompatible activities Hyperarousal Cognitive Cognitive Therapy Unrealistic sleep expectations Misconceptions about sleep Sleep anticipatory anxiety Poor coping skills Educational Sleep Hygiene Sleep Education Inadequate sleep hygiene Motivation/Treatment rationale

39 A Study to Test Brief CBT-I in in VA Primary Care (PC) patients with depression and insomnia Small Randomized Controlled Trial CT comparing: 4-session CBT for Insomnia (CBT-I; n=13) 2-session Sleep Hygiene (SH; n=15) Potential subjects: identified from annual PC depression screener Pigeon (PI)

40 Results: Sleep Diary Data Within Group Time x Group TX Cond Pre-TX Post-TX sig. d sig. d SL CBT-I 43.8 (29.2) 18.9 ( 9.8) * 1.19 * 0.55 SH 34.1 (32.7) 36.1 (42.6) ns 0.05 NOA CBT-I 2.8 ( 1.6) 1.4 ( 0.9) ** 1.14 * 0.60 SH 2.5 ( 1.6) 2.1 ( 1.2) ns 0.34 WASO CBT-I 79.4 (65.8) 28.7 (24.2) * 1.06 ** 0.71 SH 58.5 (43.4) 55.8 (48.9) ns 0.12 TST CBT-I (60.8) (88.1) ns 0.27 ns 0.15 SH (113.5) (155.9) ns 0.12 SE CBT-I 75.4 (12.6) 86.7 (12.1) **.95 * 0.44 SH 79.8 ( 7.7) 80.5 (16.3) ns 0.06 Repeated Measures ANOVA; * p <.05; ** p <.01 40

41 Brief CBT-I in PC: Study #2 Brief CBT-I (n=23) vs. TAU (n=27) in VA PC Potential subjects: identified from electronic medical record DXs recruited by introductory letter from their PCP assessed and treated in a co-located PC office progress notes co-signed by PCP Criteria included: endorsing SI (without current intent) Dx d with Major Depressive Disorder and/or PTSD Insomnia Severity Index (ISI) score > 10 + trouble sleeping > 3 months + > 1 daytime consequence Pigeon (PI) VA HSRD I21 HX

42 Brief CBT-I Intervention Individual therapy supplemented by workbook Four Sessions averaging ~ 30 min Content: Sleep Psychoeducation Stimulus Control Sleep Restriction Cognitive Therapy Sleep Hygiene Relapse Prevention Sessions audio-recorded and rated for treatment fidelity 42

43 Outcome Questionnaires Insomnia Severity Index (ISI) Patient Health Questionnaire (PHQ-9) Columbia-Suicide Severity Rating Scale (C-SSRS) Suicidal Ideation (0-5 categorical scale) Intensity of Ideation (5 items, 1-25 continuous scale) Suicidal Behaviors 43

44 ISI Total Score Results: Insomnia Severity Index Pre Post ANCOVAs adjusting for baseline values p <.001; ES = TAU CBT-I 44

45 PHQ-9 Total Score (minus sleep) Results: Depression Severity (PHQ- 8 ) Pre Post ANCOVAs adjusting for baseline values p <.01; ES = TAU CBT-I 45

46 C-SSRS SI Intensity Subscale Results: SI Severity (C-SSRS subscale) Pre Post ANCOVAs adjusting for baseline values p =.153; ES = TAU CBT-I 46

47 Summary & Recommendations Summary Sleep disturbance is associated with increased risk for suicidal thought and behavior even when controlling for important risk factors (e.g., depression) Insomnia is a valid intervention target, the treatment of which, can improve multiple domains beyond sleep Early evidence suggests that CBT-I may reduce suicidal ideation, however, further study is needed What we Don t Know: Whether CBT-I reduces suicide attempts and/or suicide Whether CBT-I in depressed individuals with current SI and/or a prior suicide attempt should be delivered before, after or in-tandem with other interventions Whether patients with insomnia who are at risk for suicide should be withdrawn from hypnotic medications that are associated with suicidal ideation and treated with CBT-I. Whether nightmare or apnea treatments reduce suicidal thoughts and behaviors 47

48 Summary & Recommendations Clinical Recommendations 1. Adopt sleep quality as a vital sign 2. Continue to expand the use of brief screening tools Insomnia Severity Index (Bastien et al., 2001); Pittsburg Sleep Quality Index (Buysee et al., 1989); NIH PROMIS measures (Cella et al., 2007) 3. Consider using conversations about sleep disturbance as an opportunity to engage patients in broader discussions about mental health and a chance to ask about suicide 4. Use of CBT-I as a front line treatment for insomnia, particularly for those patients known to be at greater risk for suicide

49 Summary & Recommendations Future Directions for Research Examine specific impact of unique sleep disorders on suicidal thought and behavior Expand beyond subjective measures of sleep quality to in depth examinations of sleep architecture and depression and suicide Explore the best sequencing of treatments (e.g., CBT-I preceding or following treatment for PTSD) Investigations of the relationship of sleep disturbance to suicidal thought and behavior during transitions in care 49

50 Additional Resources American Foundation for Suicide Prevention: American Association of Suicidology: American Academy of Sleep Medicine: National Sleep Foundation: Veterans Crisis Line: Treating Insomnia in Primary Care: Pigeon WR, Funderburk J. (2014) Delivering a brief insomnia intervention to depressed VA primary care patients. Cognitive Behavioral Practice, 21: Bishop TM & Pigeon WR. (2014). Using Behavioral Therapies in Primary Care. In Primary Care Sleep Medicine (pp ). Springer New York. Goodie JL & Hunter CL. (2014). Practical Guidance for Targeting Insomnia in Primary Care Settings. Cognitive and Behavioral Practice.

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