Marine Intercept Program: The Evolution of Caring Contacts Headquarters, United States Marine Corps August 2017 Mary Ellen Stone Point of Contact: Mary.stone@usmc.mil 703-784-1284 v1

Purpose Overview of “caring contacts” Systematic literature review Marine Intercept Program (MIP) background Preliminary descriptive analysis results of USMC MIP Discussion 11/17/2018 v1

Caring Contacts Motto (1976), Motto and Bostrom (2001) Provide caring contacts to individuals post-discharge Letters, emails, texts, in-person contact, phone calls, postcards Researcher, care provider, social worker, psychiatrist, case manager, etc. 11/17/2018 v1

Literature Review Inclusion criterion: Empirical or systematic literature review, US/UK/Australia/Canada/Japan, suicide ideation (SI)/suicide attempt (SA)/Death outcome 2000-2016 Must contain a caring contact component (not just case management) Search terms using Web of Science and Google Scholar: “suicide,” “caring contact,” “brief intervention contact,” “suicidal” Sample size: 13 11/17/2018 v1

Literature Review Reference Outcome Main Findings Design Beautrais et al., 20101 Repeated self-harm No significant differences when controlled for previous self-harm Postcard intervention may be effective only for selected sub-groups Randomized Controlled Trials (RCT) Emergency Department Carter et al., 20051 Self-poisoning No significant differences (significant in unadjusted analysis) RCT hospital patients Carter et al., 20071 No significant reduction in proportion of repeating self-poisoning in postcard group Significant reduction in the rate of repetition (small effect size) RCT follow-up Carter et al., 20131 Self-poisoning, psychiatric admissions No difference between groups for any repeat episode self-poisoning admissions or psychiatric admission, but a significant reduction in event rates Chesin & Stanley, 20132 Psychosocial suicide interventions Mixed results Recommend more rigorous studies Literature review Comtois & Linehan, 20062 Psychosocial suicide treatments No effective intervention in preventing completed suicide except Motto & Bostrom (2001) Daigle et al., 20111,3,4 Tertiary interventions of suicide attempt (SA) Caring contact interventions vary significantly in their implementation Recommend more rigorous studies and standardizing implementation Harmon et al. 20102 Military suicide prevention Lack of empirical evidence demonstrating effective suicide prevention programs within U.S. services Hawton et al., 20161 Suicide, suicide ideation (SI), SA No significant effects for postcards on deaths by suicide in four post-interventions One trial showed significant treatment effect for suicidal ideation Meta-analysis of RCTs (Beautrais et al., 2010 and Carter et al., 2005) Lizardi & Stanley, 20102,3,4 Treatment suicide attempt Found no caring contact interventions had long-term effect in reducing number of repeat attempts Luxton et al., 20132 Suicide, SA, SI Repeated follow-up contacts may have a preventive effect on suicidal behaviors. Milner et al., 20151,2,4,5 Brief contact suicide interventions Results vary significantly No significant reduction in the odds of suicide Contact interventions cannot be recommended for widespread clinical implementation, need further assessment Meta-analysis of RCTs (Beautrais et al., 2010; Motto & Bostrom, 2001; Carter et al., 2013) Motto & Bostrom 20012 Suicide rate Survival curves showed significantly lower rate at two years, differences in rates diminished thereafter RCT psychiatric inpatients 1 Postcards, 2 Letters/emails, 3 In-person, 4 Telephone, 5 Green card/crisis card Design: literature review, meta-analysis, RCT, follow-up, etc. No case management. Has to incorporate a caring contact component. Self-harm and self-poisoning are indicators of suicide risk. Randomized controlled trial 11/17/2018 v1

Literature Review - Conclusions Effectiveness Best practices identified or patterns which appear to be most effective (if possible) Limitations 11/17/2018 v1

Literature Review – Future Research Needs RCTs and replication to discern effectiveness and effect size Best practices (mode, duration, frequency, contact provider) Cost effectiveness Application to both SIs and SAs Military application and evaluation Should caring contact look the same for military population? Marine Intercept Program 11/17/2018 v1

MIP Background Purpose of MIP is to prevent repeat suicide ideations and/or attempts, as well as death by suicide. Protocol 1, 3, 7, 14, 30, 60, and 90 days Phone call with MIP counselor (Community Counseling Program clinician) Caring contact, suicide screener (Columbia Suicide Severity Rating Scale), Veterans Affairs Safety Plan Tracking Suicide Tracking and Reporting Tool (START) Update Commander per their request or if having difficulty reaching Marine or attached Sailor 11/17/2018 v1

Preliminary Descriptive Results of USMC MIP   MIP Participant (2,242) Declined MIP (628) Not Offered MIP (658) Totals (3,528) Gender Male 83% (1,856) 80% (497) 84% (546) 83% (2,899) Female 17% (379) 20% (128) 16% (101) 17% (608) 100% (2235) 100% (625) 100% (647) 100% (3,507) Race White 63% (1,379) 64% (395) 66% (417) 63% (2,191) African American 12% (256) 13% (78) 12% (75) 12% (409) American Indian/Alaskan 2% (41) -- 2% (13) 2% (63) Asian 3% (68) 3% (94) Hawaiian/Pacific Islander <1% (17) <1% (26) Hispanic 16% (344) 15% (93) 14% (86) 15% (523) Other/Declined 4% (99) 4% (24) 4% (25) 4% (148) 100% (2,204) 98% (615) 100% (635) 100% (3,454) Marital Status Single 61% (1324) 60% (364) 60% (377) 60% (2065) Married 37% (809) 37% (223) 37% (234) 37% (1,266) Divorced 2% (49) 3% (19) 3% (18) 3% (86) 100% (2,182) 100% (606) 100% (629) (3,417) Zero cells or n<10 for legally separated and widowed categories. 99% of MIP Participants Marines, 98% Declined MIP Marines, 100% not offered MIP Marines. 11/17/2018 v1

Frequency of MIP Participation Type by Calendar Year Chi-square = 51.1 p<.0001 11/17/2018 v1

Frequency of History of Suicide Attempt and/or Ideation Chi-square = 10.0 p<.01 11/17/2018 v1

Frequency of Participation Type by Age Cells with zeros have been removed from analysis. Chi-square = 84.2 p<.01 11/17/2018 v1

Discussion Caring contacts may have roots in the 1970s, but the intervention is still in its infancy regarding best practices and effectiveness. Further research, especially within the military population, is necessary to determine effectiveness, cost-effectiveness, impact, and best practices. Empirical literature indicates that caring contacts have potential, but there are several limitations and gaps in knowledge to implement caring contacts service-wide. MIP will require a comprehensive evaluation, beginning with implementation. 11/17/2018 v1

HQMC Marine & Family Programs Division, Behavioral Health Branch Contact Information Mary Ellen Stone Mary.Stone@usmc.mil HQMC Marine & Family Programs Division, Behavioral Health Branch