Effect of Augmenting Standard Care for Military Personnel With Brief Caring Text Messages for Suicide Prevention

Abstract

IMPORTANCE Accessible and cost-effective interventions for suicidality are needed to address high rates of suicidal behavior among military service members. Caring Contacts are brief periodic messages that express unconditional care and concern and have been previously shown to prevent suicide deaths, attempts, ideation, and hospitalizations. OBJECTIVE To test the effectiveness of augmenting standard military health care with Caring Contacts delivered via text message to reduce suicidal thoughts and behaviors over 12 months. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted at 3 military installations in the southern and western United States. Soldiers and Marines identified as being at risk of suicide were recruited between April 2013 and September 2016. The final follow-up was in September 2017. INTERVENTIONS Both groups received standard care, and the Caring Contacts group also received consisted of 11 text messages delivered on day 1, at week 1, at months 1, 2, 3, 4, 6, 8, 10, and 12, and on participants' birthdays. MAIN OUTCOMES AND MEASURES Primary outcomes were current suicidal ideation and suicide risk incidents (hospitalization or medical evacuation). Secondary outcomes were worst-point suicidal ideation, emergency department visits, and suicide attempts. Suicidal ideation was measured by the Scale for Suicide Ideation, suicide risk incidents, and emergency department visits by the Treatment History Interview; attempted suicide was measured by the Suicide Attempt Self-Injury Count. RESULTS Among 658 randomized participants (329 randomizely assigned to each group), data were analyzed for 657 individuals (mean [SD] age, 25.2 [6.1] years; 539 men [82.0%]). All participants reported suicidal ideation at baseline, and 291 (44.3%) had previously attempted suicide. Of the 657 participants, 461 (70.2%) were assessed at 12 months. Primary outcomes were nonsignificant. There was no significant effect on likelihood or severity of current suicidal ideation or likelihood of a suicide risk incident; there was also no effect on emergency department visits. However, participants who received Caring Contacts (172 of 216 participants [79.6%]) had lower odds than those receiving standard care alone (179 of 204 participants [87.7%]) of experiencing any suicidal ideation between baseline and follow-up (odds ratio, 0.56 [95% CI, 0.33-0.95]; P = .03) and fewer had attempted suicide since baseline (21 of 233 [9.0%] in the group receiving Caring Contacts vs 34 of 228 [14.9%] in the standard-care group; odds ratio, 0.52 [95% CI, 0.29-0.92]; P = .03). CONCLUSIONS AND RELEVANCE This trial provides inconsistent results on the effectiveness of caring text messages between primary and secondary outcomes, but this inexpensive and scalable intervention offers promise for preventing suicide attempts and ideation in military personnel. Additional research is needed.

Perceived burdensomeness, bullying, and suicidal ideation in suicidal military personnel

“…This study utilized baseline data collected before randomization from a larger treatment effectiveness trial, known as the Military Continuity Project (MCP; Comtois et al, 2019) with the following inclusion criteria: (a) Active duty, Reserve, National Guard, (b) 18 or more years of age, (c) English speaking, (d) identification to a behavioral health or medical service (inpatient, outpatient, or emergency) due to suicidal behavior-either suicidal ideation or a suicide attempt, (e) has current suicidal ideation as defined by a score of 1 or more on the Scale for Suicide Ideation, and (f) mobile phone or pager that can affordably receive 11 text messages in a year. Exclusion criteria were (a) too cognitively impaired at best mental status to consent, (b) treating clinician evaluates the intervention as contraindicated (for instance, paranoia may be exacerbated by being contacted), (c) prisoner or otherwise under judicial order such that study participation could not be considered to be truly voluntary, or (d) doesn't speak and read English well enough to consent and to understand texts in English.…”

Caring E‐mails for Military and Veteran Suicide Prevention: A Randomized Controlled Trial

“…This study describes the results from the first RCT of an e‐mail version of the CL intervention. Prior research on caring messages has reported promising, but mixed results with a variety of outcomes (Comtois et al., ; Luxton, June et al., ). One trial conducted in the United States in the 1970s with postal mail reported reduced suicide rates compared to a group that did not receive letters, but only for the first two years of the intervention (Motto, ; Motto & Bostrom, ).…”

“…While there are several RCTs that support the efficacy of caring contact interventions in reducing rates of a variety of suicide behaviors (Carter, Clover, Whyte, Dawson, & D'Este, , ; Hassanian‐Moghaddam, Sarjami, Kolahi, & Carter, ), several trials have reported null results (Cedereke, Monti, & Ojenhagen, ; Comtois et al., ; Larkin & Beautrais, ). For example, Comtois et al.…”

“…For example, Comtois et al. () conducted a randomized controlled trial of a caring texting intervention that included 658 U.S. Soldiers and Marines.…”

A Preliminary Precision Treatment Rule for Remission of Suicide Ideation

“…Because of this likely presence of HTE, it is important not to reject SRIB‐focused interventions prematurely based on their generally weak aggregate effects. For example, if HTE existed in the “caring text” RCT recently reported by Comtois et al (), then the relatively modest aggregate effects dismissed in an editorial of that study as predominantly null (Hoge, ) might have masked a (perhaps substantially) stronger effect in the (possibly small) subset of patients helped by the intervention, which might make that intervention a valuable component in a multimodal SRIB prevention strategy. However, it is unknown whether HTE existed because the trial was not designed to study this possibility (either in terms of targeted sampling or comprehensive assessment of hypothesized baseline modifiers).…”