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Principal Investigator: Michael Esterman
Organization: VA BOSTON HEALTH CARE SYSTEM
Fiscal Year: 2024
Funding agency: Veterans Affairs
The suicide rate among active duty service members and veterans increased substantially following the
onset of post-9/11 conflicts in Iraq and Afghanistan1. Accordingly, veteran suicide prevention has been
identified as a national healthcare and research priority2. Psychosocial interventions for suicide risk vary
substantially in dose and resource allocation. A single therapy session designed to evaluate risk factors and
provide support resources (e.g., Enhanced Crisis Response Plans [ECRP]3) has been shown to reduce risk for
future suicide attempts. Other interventions consisting of 10-12 outpatient sessions following inpatient
discharge (e.g., Brief Cognitive Behavioral Therapy for suicide prevention [BCBT]4) have been shown to
reduce suicide attempts by 50-60% relative to treatment as usual. Although both forms of intervention have
been shown to reduce risk, interventions that vary in dose and resource allocation have yet to be directly
compared, leaving two critical gaps in our ability to intervene most effectively. First, the assumption that more
time- and resource-intensive 10-12 session interventions translate to greater suicide risk reduction has yet to
be demonstrated. Second, it may be that less resource intensive interventions are adequate for some
individuals whereas others require more intensive care. To date, there is no evidence to guide what
interventions are indicated for specific clinical presentations.
Pharmacological and brain stimulation interventions for suicide risk are extremely limited. This is due, in
part, to an incomplete understanding of the neurobiological mechanisms of suicide risk. Although numerous
studies have examined cross-sectional neuroimaging correlates of current suicide ideation or compared
individuals with and without history of a suicide attempt, to date no studies have examined a) neurobiological
predictors of future suicide attempts in high-risk samples, b) how changes in neurobiological markers over time
relate to changes in suicide risk, or c) theoretically and mechanistically relevant neuroimaging procedures in a
prospective design. Cross-sectional research examining neuroimaging markers of past or current self-injurious
thoughts and behaviors (SITBs) has identified dysfunction in regions associated with emotion regulation,
inhibitory control, and decision-making5,6, namely in cognitive control networks (CCN). On the other hand,
dysfunction has also been observed in regions associated with negative affect and rumination such as limbic
(LN) and default mode (DMN) networks. Despite these cross-sectional findings, identification of neuroimaging
predictors of future suicide attempts, and neural markers of successful suicide risk intervention outcomes
represents a completely novel, critical step to guiding optimal targeting of neurobiologically-informed
interventions and translating neuroimaging of suicide into practice. Whether these potential neuroimaging
predictors are identifiable during resting state, or whether more suicide-relevant cognitive tasks are required,
such as death-related bias or inhibitory control, remains an open yet critical question.
The purpose of our proposed study is to compare two evidence-based suicide risk interventions that
vary in dose in order to a) directly test if a more intensive intervention produces greater risk reduction, b)
identify veterans for whom a more intensive intervention is indicated, and c) identify resting-state and task-
based neurobiological markers of future suicide attempts and examine how changes in these markers relate to
changes in suicide risk over time. We will recruit and evenly randomize 136 male and female veterans
hospitalized for suicide risk to ECRP or BCBT. We will collect neuroimaging data immediately upon discharge,
post-treatment, and 12-months post-discharge and assess SITBs out to 12-months post-discharge.
Terms: <Active Follow-up><Address><Afghanistan><After Care><After-Treatment><Aftercare><Behavior><Belief><Brain><Brain Nervous System><Cessation of life><Characteristics><Clinical><Cognition><Cognition Therapy><Cognitive Psychotherapy><Cognitive Therapy><Cognitive treatment><Data><Death><Decision Making><Dose><Dysfunction><Emotional><Encephalon><Evidence based intervention><Feeling suicidal><Female><Functional MRI><Functional Magnetic Resonance Imaging><Functional disorder><Future><Healthcare><History><Hospital Admission><Hospitalization><Individual><Inpatients><Intensive Care><Intervention><Intervention Strategies><Iraq><Literature><Neurobiology><Out-patients><Outcome><Outpatients><Pattern><Physiopathology><Prediction of Response to Therapy><Preventative intervention><Procedures><Randomized><Recording of previous events><Research><Research Priority><Research Resources><Resource Allocation><Resources><Rest><Risk Factors><Risk Reduction><Sampling><Self Assessment><Suicidal thoughts><Suicide><Suicide attempt><Suicide precaution><Suicide prevention><Testing><Thinking><Time><Translating><Treatment outcome><Veterans><active duty><active followup><active service><care as usual><cognitive behavior intervention><cognitive behavior modification><cognitive behavior therapy><cognitive behavioral intervention><cognitive behavioral modification><cognitive behavioral therapy><cognitive behavioral treatment><cognitive control><cognitive task><comparable efficacy><comparative efficacy><compare efficacy><compare treatment><design><designing><emotion dysregulation><emotion regulation><emotional dysregulation><emotional regulation><evidence base><experience><fMRI><fatal attempt><fatal suicide><follow up><follow-up><followed up><followup><health care><high risk><histories><intent to die><intervention for prevention><interventional strategy><male><military member><negative affect><negative affectivity><neural><neural imaging><neuro-imaging><neurobiological><neurobiological mechanism><neuroimaging><neuroimaging biomarker><neuroimaging marker><neurological imaging><non fatal attempt><nonfatal attempt><novel><pathophysiology><pharmacologic><post 9/11><post treatment><predict therapeutic response><predict therapy response><prevent suicidality><prevent suicide><prevention intervention><preventional intervention strategy><preventive intervention><prospective><psychosocial><randomisation><randomization><randomly assigned><recruit><reduce risk><reduce risks><reduce suicidality><reduce suicide><reduce that risk><reduce the risk><reduce these risks><reduces risk><reduces the risk><reducing risk><reducing suicidality><reducing suicide><reducing the risk><response><risk-reducing><ruminate><rumination><ruminative><service member><suicidal attempt><suicidal behavior><suicidal ideation><suicidal risk><suicidal thinking><suicidality prevention><suicide behavior><suicide ideation><suicide intervention><suicide rate><suicide risk><suicides><therapy prediction><thoughts><thoughts about suicide><treatment as usual><treatment comparison><treatment prediction><treatment response prediction><usual care>