Advertisement

An Evaluation of the Effectiveness of Evidence-Based Psychotherapies for Depression to Reduce Suicidal Ideation among Male and Female Veterans

  • Mandy J. Kumpula
    Correspondence
    Correspondence to: Mandy J. Kumpula, PhD, Veterans Health Administration, 2851 University Avenue, Green Bay, WI 54311. Phone: (414) 573-3587; fax: (920) 431-2940.
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia

    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina
    Search for articles by this author
  • H. Ryan Wagner
    Affiliations
    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
    Search for articles by this author
  • Eric A. Dedert
    Affiliations
    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina

    Mental Health Service Line, Durham Veterans Affairs Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
    Search for articles by this author
  • Chris M. Crowe
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia
    Search for articles by this author
  • Kristine T. Day
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia

    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina
    Search for articles by this author
  • Kristin Powell
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia

    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina
    Search for articles by this author
  • Wendy H. Batdorf
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia

    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina
    Search for articles by this author
  • Hani Shabana
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia

    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina
    Search for articles by this author
  • Ellie Kim
    Affiliations
    Department of Veterans Affairs Office of Mental Health and Suicide Prevention, Washington, District of Columbia

    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina
    Search for articles by this author
  • Nathan A. Kimbrel
    Affiliations
    Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina

    Mental Health Service Line, Durham Veterans Affairs Medical Center, Durham, North Carolina

    Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina

    Department of Veterans Affairs, Durham Center for Health Services Research in Primary Care, Durham, North Carolina
    Search for articles by this author

      Abstract

      Background

      Although most suicide-related deaths occur among male veterans, women veterans are dying by suicide in increasing numbers. Identifying and increasing access to effective treatments is imperative for Department of Veterans Affairs suicide prevention efforts. We examined the impact of evidence-based psychotherapies for depression on suicidal ideation and the role of gender and treatment type in patients’ responses to treatment.

      Methods

      Clinicians receiving case consultation in interpersonal psychotherapy, cognitive–behavioral therapy for depression, and acceptance and commitment therapy for depression submitted data on depressive symptoms and suicidal ideation while treating veterans with depression.

      Results

      Suicidal ideation was reduced across time in all three treatments. A main effect for wave was associated with statistically significant decreases in severity of suicidal ideation, χ2 (2) = 224.01, p = .0001, and a subsequent test of the Gender × Wave interaction was associated with differentially larger decreases in ideation among women veterans, χ2 (2) = 9.26, p = .001. Within gender-stratified subsamples, a statistically significant Treatment × Time interaction was found for male veterans, χ2 (4) = 16.82, p = .002, with levels of ideation significantly decreased at waves 2 and 3 in interpersonal psychotherapy and cognitive–behavioral therapy for depression relative to acceptance and commitment therapy for depression; the Treatment × Wave interaction within the female subsample was not statistically significant, χ2 (4) = 3.41, p = .492.

      Conclusions

      This analysis demonstrates the efficacy of each of the three tested evidence-based psychotherapies for depression as a means of decreasing suicidal ideation, especially in women veterans. For male veterans, decreases in suicidal ideation were significantly greater in interpersonal psychotherapy and cognitive–behavioral therapy for depression relative to acceptance and commitment therapy for depression.
      Suicide prevention is a top clinical priority within the Department of Veterans Affairs (VA). In response, the Veterans Health Administration (VHA) has called for expanded access to and engagement in effective treatments to prevent veteran suicide (
      U.S. Department of Veterans Affairs (VA)
      VA National Suicide Data Report 2005-2015.
      ). The number of veterans dying by suicide in the United States has been increasing, and although the majority of suicide-related decedents among veterans are men, women veterans are dying by suicide in increasing numbers (
      U.S. Department of Veterans Affairs (VA)
      VA National Suicide Data Report 2005-2015.
      ). From 1999 through 2014, the suicide rate among women veterans rose by 62.4%, compared with a rate increase of 29.7% among male veterans (
      U.S. Department of Veterans Affairs (VA), Office of Mental Health and Suicide Prevention (OMHSP)
      Facts About Suicide Among Women Veterans: August 2017.
      ), and the rate of suicide for women veterans is twice that of nonveteran adult women (
      U.S. Department of Veterans Affairs (VA)
      VA National Suicide Data Report 2005-2015.
      ). The risk of suicide among women veterans using VHA services has also increased in recent years, from 14.4 per 100,000 in 2001 to 17.3 per 100,000 in 2014 (
      U.S. Department of Veterans Affairs (VA), Office of Mental Health and Suicide Prevention (OMHSP)
      Facts About Suicide Among Women Veterans: August 2017.
      ). The narrowing of the gender gap in suicide risk and the expanding concurrent risk of death by suicide among women veterans make it imperative that women veterans have access to effective treatments to address these risks.
      Despite an extensive body of literature aiming to identify risk factors for suicide, a recent meta-analytic review concluded that existing research does not establish accurate or reliable predictors of suicide and “cannot provide much useful information about treatment and prevention targets,” appealing for improved methodology in suicide research (
      • Franklin J.C.
      • Ribeiro J.D.
      • Fox K.R.
      • Bentley K.H.
      • Kleiman E.M.
      • Huang X.
      • Nock M.K.
      Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research.
      ). Amidst an ongoing evolution of empirical knowledge, the VA is tasked with addressing increasing rates of suicide among veterans and taking into account the unique contributions of gender.
      Depressive disorders are a frequently cited risk factor for suicide (
      • Arsenault-Lapierre G.
      • Kim C.
      • Turecki G.
      Psychiatric diagnoses in 3275 suicides: A meta-analysis.
      ,
      • Cavanagh J.T.
      • Carson A.J.
      • Sharpe M.
      • Lawrie S.M.
      Psychological autopsy studies of suicide: A systematic review.
      ,
      • Harris E.C.
      • Barraclough B.
      Suicide as an outcome for mental disorders: A meta-analysis.
      ,
      • Holma K.M.
      • Haukka J.
      • Suominen K.
      • Valtonen H.M.
      • Mantere O.
      • Melartin T.K.
      • Isometsä E.T.
      Differences in incidence of suicide attempts between bipolar I and II disorders and major depressive disorder.
      ,
      • Nock M.K.
      • Hwang I.
      • Sampson N.
      • Kessler R.C.
      • Angermeyer M.
      • Beautrais A.
      • De Graaf R.
      Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys.
      ,
      • Nordentoft M.
      • Mortensen P.B.
      Absolute risk of suicide after first hospital contact in mental disorder.
      ) and, hence, provide a potential target for suicide prevention among women veterans. Women are more frequently diagnosed with depressive disorders than are men (
      • Kessler R.C.
      • Berglund P.
      • Demler O.
      • Jin R.
      • Koretz D.
      • Merikangas K.R.
      • Wang P.S.
      The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R).
      ), and the association between depressive disorders and suicide risk is more substantial among women (
      • Arsenault-Lapierre G.
      • Kim C.
      • Turecki G.
      Psychiatric diagnoses in 3275 suicides: A meta-analysis.
      ). Frequency of depression is also higher for women than men within the veteran population (
      • Curry J.F.
      • Aubuchon-Endsley N.
      • Brancu M.
      • Runnals J.J.
      • Fairbank J.A.
      Lifetime major depression and comorbid disorders among current-era women veterans.
      ,
      • Davis T.D.
      • Campbell D.G.
      • Bonner L.M.
      • Bolkan C.R.
      • Lanto A.
      • Chaney E.F.
      • Rubenstein L.V.
      Women veterans with depression in Veterans Health Administration primary care: An assessment of needs and preferences.
      ,
      • Maguen S.
      • Ren L.
      • Bosch J.O.
      • Marmar C.R.
      • Seal K.H.
      Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care.
      ,
      • Seal K.H.
      • Metzler T.J.
      • Gima K.S.
      • Bertenthal D.
      • Maguen S.
      • Marmar C.R.
      Trends and risk factors for mental health diagnoses among Iraq and Afghanistan Veterans using Department of Veterans Affairs healthcare, 2002–2008.
      ), with one study reporting that 46.5% of women veterans meet criteria for major depressive disorder during their lifetime (
      • Curry J.F.
      • Aubuchon-Endsley N.
      • Brancu M.
      • Runnals J.J.
      • Fairbank J.A.
      Lifetime major depression and comorbid disorders among current-era women veterans.
      ). Recurring thoughts of death or suicide are one of the nine symptoms characterizing major depressive disorder (
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders (DSM-5®).
      ), highlighting an explicit link between depression and suicide risk. Women have higher lifetime prevalence of suicide ideation (20.1% vs. 12.7%) and twice the rate of lifetime suicide attempts compared with men (5.1% vs. 2.5%), and much of the increased risk of suicide attempts for women may be accounted for by increased ideation (
      • Millner A.J.
      • Ursano R.J.
      • Hwang I.
      • King A.J.
      • Naifeh J.A.
      • Sampson N.A.
      • Nock M.A.
      Lifetime suicidal behaviors and career characteristics among U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
      ). After examining predictive associations between mental health disorders and risk of death by suicide,
      • Nock M.K.
      • Hwang I.
      • Sampson N.
      • Kessler R.C.
      • Angermeyer M.
      • Beautrais A.
      • De Graaf R.
      Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys.
      concluded that depression is among the strongest predictors of suicide attempts, owing in large part to depression predicting the onset of suicidal ideation. In contrast, a thorough meta-analysis conducted by
      • Franklin J.C.
      • Ribeiro J.D.
      • Fox K.R.
      • Bentley K.H.
      • Kleiman E.M.
      • Huang X.
      • Nock M.K.
      Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research.
      did not identify internalizing disorders or suicidal ideation as substantial predictors of later suicidal behavior or death by suicide, leaving conclusions about the nature of these relationships unsettled.
      The presence of heightened risk of suicide in veterans with depression is recognized in the VA/Department of Defense Clinical Practice Guideline for the Assessment and Management of Patients at Risk of Suicide (
      U.S. Department of Veterans Affairs (VA), Office of Quality Safety and Value
      VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide.
      ), which states, “research suggests that the effective treatment of mental health conditions (particularly major depression) reduces the risk of suicide and may decrease suicide rates.” Further, the VA/Department of Defense Clinical Practice Guideline recommends that “patients receive optimal evidence-based treatment for any mental health and medical conditions that may be related to the risk of suicide.” Among the first-line treatments recommended for major depressive disorder are evidence-based psychotherapies (EBPs), including cognitive–behavioral therapy for depression (CBT-D), interpersonal psychotherapy (IPT), and acceptance and commitment therapy for depression (ACT-D). CBT-D is a time-limited, structured psychotherapy that encourages behavioral changes that reduce depression, such as increases in pleasurable activities, and guides the patient through restructuring cognitions and beliefs that maintain depression. IPT addresses the relationship between adverse life events and depression by facilitating focus on processing affect related to interpersonal relationships (
      • Markowitz J.C.
      • Weissman M.M.
      Interpersonal psychotherapy: Past, present and future.
      ,
      • Sullivan H.S.
      The interpersonal theory of psychiatry.
      ). ACT-D treats depression by encouraging acceptance of internal experiences and alignment of behavior with intrinsic motivations (
      • Hayes S.C.
      • Levin M.E.
      • Plumb-Vilardaga J.
      • Villatte J.L.
      • Pistorello J.
      Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy.
      ). Clinical trials have established the efficacy of CBT-D (
      • Hofmann S.G.
      • Asnaani A.
      • Vonk I.J.
      • Sawyer A.T.
      • Fang A.
      The efficacy of cognitive behavioral therapy: A review of meta-analyses.
      ), IPT (
      • Cuijpers P.
      • Geraedts A.S.
      • van Oppen P.
      • Andersson G.
      • Markowitz J.C.
      • van Straten A.
      Interpersonal psychotherapy for depression: A meta-analysis.
      ), and ACT-D (
      • Öst L.G.
      The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis.
      ) in reducing depressive symptoms. Within veteran populations, large within-group reductions in depressive symptoms have been observed in VHA clinical effectiveness studies of each intervention (CBT-D:
      • Karlin B.E.
      • Brown G.K.
      • Trockel M.
      • Cunning D.
      • Zeiss A.M.
      • Taylor C.B.
      National dissemination of cognitive behavioral therapy for depression in the Department of Veterans Affairs health care system: Therapist and patient-level outcomes.
      ; IPT:
      • Stewart M.O.
      • Raffa S.D.
      • Steele J.L.
      • Miller S.A.
      • Clougherty K.F.
      • Hinrichsen G.A.
      • Karlin B.E.
      National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and patient-level outcomes.
      ; and ACT-D:
      • Walser R.D.
      • Karlin B.E.
      • Trockel M.
      • Mazina B.
      • Taylor C.B.
      Training in and implementation of acceptance and commitment therapy for depression in the Veterans Health Administration: Therapist and patient outcomes.
      ). Although the efficacy of each of these interventions is established, the role of gender is not (for a review, see
      • Parker G.
      • Blanch B.
      • Crawford J.
      Does gender influence response to differing psychotherapies by those with unipolar depression?.
      ). Some studies have demonstrated greater symptom reduction for women (
      • Evans C.
      Cognitive–behavioural therapy with older people.
      ,
      • Spek V.
      • Nyklíček I.
      • Cuijpers P.
      • Pop V.
      Predictors of outcome of group and internet-based cognitive behavior therapy.
      ), some report better treatment outcomes in men (
      • Bockting C.L.
      • Spinhoven P.
      • Koeter M.W.
      • Wouters L.F.
      • Visser I.
      • Schene A.H.
      Differential predictors of response to preventive cognitive therapy in recurrent depression: A 2-year prospective study.
      ,
      • Thase M.E.
      • Reynolds C.F.
      • Frank E.
      • Simons A.D.
      • McGeary J.
      • Fasiczka A.L.
      • Garamoni G.G.
      • Jennings J.R.
      • Kupfer D.J.
      Do depressed men and women respond similarly to cognitive behavior therapy?.
      ), and others show equivalence across gender (
      • Jarrett R.B.
      • Eaves G.G.
      • Grannemann B.D.
      • Rush A.J.
      Clinical, cognitive, and demographic predictors of response to cognitive therapy for depression: A preliminary report.
      ,
      • McEvoy P.M.
      • Nathan P.
      Effectiveness of cognitive behavior therapy for diagnostically heterogeneous groups: A benchmarking study.
      ,
      • Scott J.
      Cognitive therapy for depression.
      ,
      • Watson H.J.
      • Nathan P.R.
      Role of gender in depressive disorder outcome for individual and group cognitive–behavioral treatment.
      ).
      Although the effects of EBPs for depression on suicidality have not been explored thoroughly, available evidence suggests that these treatments are effective in reducing suicidal ideation. CBT-D and ACT-D were reported to reduce suicidal ideation specifically among veterans (
      • Brown G.K.
      • Karlin B.E.
      • Trockel M.
      • Gordienko M.
      • Yesavage J.
      • Taylor C.B.
      Effectiveness of cognitive behavioral therapy for veterans with depression and suicidal ideation.
      ,
      • Walser R.D.
      • Garvert D.W.
      • Karlin B.E.
      • Trockel M.
      • Ryu D.M.
      • Taylor C.B.
      Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in veterans.
      ), and both IPT and CBT-D were shown effective in diminishing thoughts of suicide in a civilian sample (
      • Weitz E.
      • Hollon S.D.
      • Kerkhof A.
      • Cuijpers P.
      Do depression treatments reduce suicidal ideation? The effects of CBT, IPT, pharmacotherapy, and placebo on suicidality.
      ). Regarding gender,
      • Krysinska K.
      • Batterham P.J.
      • Christensen H.
      Differences in the effectiveness of psychosocial interventions for suicidal ideation and behaviour in women and men: A systematic review of randomised controlled trials.
      reported superior responses to treatment among women in 33% of the studies they reviewed in a systematic review of psychosocial interventions for suicidal ideation and behavior. Treatment efficacy in reducing suicidal ideation or suicidal behavior did not differ by gender in the remaining studies. Notably, few of the reviewed studies examined EBPs for depression. Last, previous research on IPT and CBT-D from a large nonveteran sample found no associations between gender and treatment-related reductions in suicidal ideation (
      • Weitz E.
      • Hollon S.D.
      • Kerkhof A.
      • Cuijpers P.
      Do depression treatments reduce suicidal ideation? The effects of CBT, IPT, pharmacotherapy, and placebo on suicidality.
      ). Against this conflicting background, additional research is needed to determine whether gender plays a role in moderating the effectiveness of evidence-based treatments for depression among veterans experiencing suicidal ideation.

      Objectives

      The VHA has been actively implementing a national initiative to disseminate and implement EBPs including CBT-D, IPT, and ACT-D. Since the initiative began in 2008, approximately 2,700 clinicians have received competency-based training to provide EBPs for the treatment of depression (for more details about the VA’s EBP training initiative, see
      • Karlin B.E.
      • Cross G.
      From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System.
      ). The first objective of the current program evaluation analysis was to examine the overall impact of participation in EBP for depression on suicidal ideation. We expected that participation in EBP for depression would be associated with statistically significant decreases in suicidal ideation across treatments and gender. Our second objective was to explore whether gender moderated patients’ response to treatment over time. The third and final objective was to examine whether treatment response varied by type of EBP treatment received.

      Methods

      Program Procedures

      Data for the present program evaluation analysis were collected as part of the VA EBP Training Programs for CBT-D, IPT, and ACT-D between 2008 and 2013. During this timeframe, the CBT-D, IPT, and ACT-D training programs provided competency-based training consisting of participation in a 3-day workshop followed by 6 months of weekly case consultation via telephone. Training participants were VA mental health clinicians who provided psychotherapy services to veterans with depression. Training workshops included didactic and experiential training focused on developing the knowledge and skills essential for effective treatment delivery. Case consultation involved verbal discussion of cases, review of audio-recorded therapy sessions, and support of the development and implementation of therapy-specific skills. Weekly consultation calls were conducted by trained experts in CBT-D, IPT, or ACT-D, with an average of four clinicians per consultation group. Detailed descriptions of the CBT-D, IPT, and ACT-D training programs have been previously reported by
      • Karlin B.E.
      • Brown G.K.
      • Trockel M.
      • Cunning D.
      • Zeiss A.M.
      • Taylor C.B.
      National dissemination of cognitive behavioral therapy for depression in the Department of Veterans Affairs health care system: Therapist and patient-level outcomes.
      ,
      • Stewart M.O.
      • Raffa S.D.
      • Steele J.L.
      • Miller S.A.
      • Clougherty K.F.
      • Hinrichsen G.A.
      • Karlin B.E.
      National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and patient-level outcomes.
      , and
      • Walser R.D.
      • Karlin B.E.
      • Trockel M.
      • Mazina B.
      • Taylor C.B.
      Training in and implementation of acceptance and commitment therapy for depression in the Veterans Health Administration: Therapist and patient outcomes.
      , respectively.
      The CBT-D protocol was adapted specifically for veterans and military service members and is designed to be administered in 12–16 individual sessions (
      • Karlin B.E.
      • Brown G.K.
      • Trockel M.
      • Cunning D.
      • Zeiss A.M.
      • Taylor C.B.
      National dissemination of cognitive behavioral therapy for depression in the Department of Veterans Affairs health care system: Therapist and patient-level outcomes.
      ). The IPT protocol consists of up to 16 weekly individual psychotherapy sessions across three phases of treatment: initial (sessions 1–3), intermediate (sessions 4–13), and termination (sessions 14–16;
      • Weissman M.M.
      • Markowitz J.C.
      • Klerman G.L.
      Comprehensive guide to interpersonal psychotherapy.
      ). The ACT-D protocol is a 12-session manual specific to the delivery of ACT for depression with veterans (
      • Walser R.D.
      • Sears K.
      • Chartier M.
      • Karlin B.E.
      Acceptance and commitment therapy for depression in veterans: Therapist manual.
      ). Patients were veterans with a primary presenting problem of a depressive disorder. IPT had the additional requirement that patients were experiencing current problems involving a considerable life change, conflict with an important person, interpersonal deficits, and/or the death of an important person (
      • Stewart M.O.
      • Raffa S.D.
      • Steele J.L.
      • Miller S.A.
      • Clougherty K.F.
      • Hinrichsen G.A.
      • Karlin B.E.
      National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and patient-level outcomes.
      ).
      Clinicians taking part in EBP training agreed to participate in program evaluation, which included collecting and reporting treatment outcome measures administered to at least two veterans engaged in therapy while receiving case consultation. Outcome data were collected as a part of the routine program evaluation for the VA National EBP Training Program. Data collection and statistical analyses were reviewed and determined to be consistent with nonresearch quality improvement activities by the chief consultant of the VA Office of Mental Health and Suicide Prevention.

      Measures

      Demographics

      Clinicians collected demographic information from each patient, including age, gender, level of education, race, and ethnicity.

      Depression and suicidal ideation

      The Beck Depression Inventory-II (BDI-II;
      • Beck A.T.
      • Steer R.A.
      • Brown G.K.
      Manual for the Beck Depression Inventory-II.
      ) is a well-established 21-item self-report measure used to assess depression severity. The BDI-II was administered in three waves: at the outset of treatment (before or at session 1), midtreatment (approximately session 7), and during the final session. Each item is scored on a 0 to 3 scale. The total score is the sum of all items (range, 0–63), with higher scores indicating greater symptom severity. Suicidal ideation was assessed via patients’ score on item nine of the BDI-II, which is a four-level scale where 0 = “I don't have any thoughts of killing myself”; 1 = “I have thoughts of killing myself, but I would not carry them out”; 2 = “I would like to kill myself”; and 3 = “I would kill myself if I had the chance.” Previous research identified that successive BDI-II item nine ratings were associated with increased suicide risk, with a score of 1 being an optimal cutoff for predicting long-term risk for death by suicide, and a score of 2 being predictive of more proximal suicide attempts (
      • Green K.L.
      • Brown G.K.
      • Jager-Hyman S.
      • Cha J.
      • Steer R.A.
      • Beck A.T.
      The predictive validity of the Beck Depression Inventory suicide item.
      ).

      Patients

      Data were collected from a total of 3,703 veterans who participated in CBT-D, IPT, or ACT-D for the treatment of depression. To focus this report on the effect of treatment on suicidal ideation, the sample was restricted to patients who endorsed a score of 1 or higher on item nine of the BDI-II, indicating the presence of suicidal ideation. The final analysis sample was comprised of 1,416 male veterans and 364 female veterans (21.1%), including 844 participants in CBT-D (21.7% female), 271 participants in IPT (22.8% female), and 665 patients in ACT-D (19.4% female). Notably, the prevalence of gender did not vary by treatment, χ2 (2) = 2.194, p = .34. Demographics for the sample are shown in Table 1.
      Table 1Demographic Characteristics of Patients by Type of EBP Treatment Received
      TreatmentNMean or %SD
      Total sample (N = 1,780)
       Women36420.4%
       Age52.412.6
       Caucasian136477.8%
       Education3.261.13
      IPT cohort (n = 271)
       Women5821.4%
       Age55.713.2
       Caucasian21079.8%
       Education3.171.13
      CBT-D (n = 844)
       Women18121.5%
       Age51.912.5
       Caucasian65678.8%
       Education3.191.10
      ACT-D (n = 723)
       Women12518.8%
       Age51.812.4
       Caucasian49875.8%
       Education3.381.15
      Abbreviations: ACT-D, acceptance and commitment therapy for depression; CBT-D, cognitive–behavioral therapy for depression; EBP, evidence-based psychotherapies; IPT, interpersonal psychotherapy; SD, standard deviation.
      Owing to missing data on race, denominators for calculating race proportions are n = 1,752 for total sample, n = 263 for IPT, n = 832 for, and n = 657 for ACT-D.

      Data Analysis Plan

      Evaluation of the primary outcome, suicidal ideation severity, was based on a set of generalized linear models using the GENMOD procedure available through SAS 9.4 (SAS Institute, Cary, NC). Generalized linear models are based on link functions that allow exponentially distributed variables to be modeled as linear. They also accommodate longitudinal (correlated) data using generalized estimating equations capable of incorporating a wide variety of time-dependent covariance structures. For the current analysis, the primary outcome measure, suicidal ideation severity, was analyzed using an assumed negative binomial distribution with a log link. This distribution, based on non-negative integer values, is similar to a Poisson distribution, but without the restrictive equivalence of mean and variance required of the latter. GENMOD procedures use all available pairs in estimating covariances and standard errors; under assumptions that missing data occur completely at random, these procedures have been shown to provide valid estimates. Covariance structure in all instances was assumed to be first-order autoregressive (i.e., correlations between repeated items were assumed to diminish exponentially with temporal distance). The ordinal outcome measure (BDI-II item nine) was regressed on models including various combinations of program, wave, and gender entered as both main effects and as a variety of interaction terms depending on the question; the baseline level of depression severity (operationalized as the total BDI-II score at baseline after removing item nine) was included in all models to account for initial severity of depression at the outset of treatment. In most instances, analyses were designed to test bivariate differences between conditions based on combinations of factors including gender, treatment, and wave. Specific contrasts were estimated using model-derived least square mean (LSM) estimates. Based on the substantial gender discrepancy in sample size and to avoid complexities of interpretation inherent in three-way interactions, relative efficacies of the three EBPs over time were assessed in gender-stratified subsamples. Because these analyses were primarily descriptive and exploratory, results are presented in unadjusted format.
      Primary analyses were supplemented with a secondary responder analysis, with a treatment response defined as a zero score on the BDI-II item nine suicide item as assessed at the final session; in instances when the latter was missing, the response was based on mid-session data. Proportion of treatment responses was assessed across gender and program using standard chi square analyses to assess the magnitude of proportional differences between factors.

      Results

      Overall Impact of EBP Treatment on Suicidal Ideation

      Across waves, suicidal ideation decreased sharply, both across and within genders: Summing over gender and treatment, the association between suicidal ideation and wave modeled as a main effect was statistically significant, χ2 (2) = 224.01, p = .0001, with ideation decreasing markedly at each measurement interval. Decreases were most pronounced from wave 1 to wave 2, where ideation scores decreased by 40.5% (model based), followed by a continued 16.9% decrease between wave 2 and wave 3, relative to the wave 1 score. In total, ideation scores decreased by 57.4% over the course of therapy (Table 2).
      Table 2Suicidal Ideation Scores by Wave, Gender, and Treatment
      VariableWave 1Wave 2Wave 3
      nMeanSEnMeanSEnMeanSE
      Sample mean
      Total sample (N = 1,780)1,7801.100.011,3180.680.021,0890.530.02
       Gender
      Men (n = 1416)1,4161.110.011,0170.720.028520.560.02
      Women (n = 364)3641.100.022500.620.041970.390.04
       EBP
      IPT (n = 271)2711.080.022230.640.041850.430.04
      CBT-D (n = 844)8441.110.016090.640.034810.500.03
      ACT-D (n = 665)6651.110.014860.770.034230.620.03
      Model-based least squares mean estimate
      Total sample (N = 1,780)1,7801.090.011,2670.650.031,0490.460.026
       Gender
      Men (n = 1416)1,4161.070.021,0170.710.028520.550.023
      Women (n = 364)3641.080.022500.600.051970.400.042
       EBP
      IPT (n = 271)2711.070.022200.600.061820.370.051
      CBT-D (n = 844)8441.090.015790.620.034580.470.034
      ACT-D (n = 665)6651.120.024680.740.044090.570.041
      Abbreviations: ACT-D, acceptance and commitment therapy for depression; CBT-D, cognitive–behavioral therapy for depression; EBP, evidence-based psychotherapies; IPT, interpersonal psychotherapy; SE, standard error.

      Impact of Gender on Suicidal Ideation

      Across treatments, a Gender × Time interaction was associated with reduced ideation among women veterans, χ2 (2) = 9.26, p = .001. LSM estimates between men and women favoring women were not statistically significant at wave 1 or wave 2 and emerged as statistically significant at wave 3 (LSM difference = -0.32, p = .005; Table 2; Figure 1).
      Figure thumbnail gr1
      Figure 1Plot of the Gender × Wave interaction (N = 1,780) showing reductions over time in suicidal ideation by gender.

      Impact of Type of EBP Treatment Received on Suicidal Ideation

      Across gender, a Treatment × Time interaction did not reach statistical significance, χ2 (4) = 9.21, p = .056. Within all three treatments, suicidal ideation decreased from wave 1 to wave 3 (Table 2). Comparisons between treatments at each wave were not statistically significant.

      Gender by Treatment Effects on Suicidal Ideation

      To preclude interpreting three-way interactions, analyses addressing gender-related treatment differences were conducted on gender-stratified subsets of the study cohort. Within the male cohort, the association between suicidal ideation and the difference in Wave x Treatment interaction was statistically significant, (χ2 [4] = 16.82, p = .002). Using LSM contrasts to explore wave-to-wave differences, suicidal ideation decreased over the course of therapy irrespective of treatment modality, that is, summing across treatments (Table 3), with the greatest decreases in ideation taking place moving from wave 1 to 2; changes at the treatment level were similar (Table 3). Exploring the magnitude of symptom levels between treatments by wave revealed programmatic differences. Decreases in the LSM-estimated ideation symptom levels were decreased in male patients receiving treatment in either the IPT or CBT-D modalities relative to levels in ACT-treated patients (Table 3; Figure 2) at both waves 2 and 3. Presented as percent change, based on the change in the LSM estimates for suicidal ideation at wave 1 and 3, male patients in IPT and CBT-D experienced decreases in ideation severity over the course of therapy of 61.1% and 52.6%, respectively, relative to a decrease of 41.1% for ACT-treated veterans.
      Table 3Mean Differences by Wave and Treatment and Gender
      TestWomenMen
      DiffSEz-ValPr > |z|DiffSEz-ValPr > |z|
      Differences in waves by treatment
       All
        W1 vs W20.590.087.50<.0010.490.067.71<.001
        W1 vs W31.010.119.52<.0010.700.0417.24<.001
        W2 vs W30.420.113.94<.0010.260.047.04<.001
       IPT
        W1 vs W20.660.193.41<.0010.490.067.71<.001
        W1 vs W31.290.264.99<.0010.830.098.79<.001
        W2 vs W30.630.272.300.020.340.084.02<.001
       CBT-D
        W1 vs W20.610.096.52<.0010.520.0411.95<.001
        W1 vs W30.940.137.13<.0010.750.0612.73<.001
        W2 vs W30.330.122.670.010.230.054.12<.001
       ACT
        W1 vs W20.500.105.16<.0010.320.048.07<.001
        W1 vs W30.810.136.10<.0010.530.0510.49<.001
        W2 vs W30.310.122.620.010.210.044.69<.001
      Differences in treatments by wave
       Wave 1
        IPT vs CBT0.000.040.060.95−0.030.02−1.380.17
        IPT vs ACT−0.080.05−1.470.14−0.010.02−0.540.59
        CBT vs ACT−0.080.04−1.900.060.020.021.070.29
       Wave 2
        IPT vs CBT−0.050.23−0.220.820.000.08−0.060.95
        IPT vs ACT−0.240.22−1.060.29−0.180.08−2.400.02
        CBT vs ACT−0.190.13−1.410.16−0.180.06−2.930.00
       Wave 3
        IPT vs CBT−0.340.29−1.180.21−0.120.11−1.030.30
        IPT vs ACT−0.560.29−1.920.06−0.320.11−2.860.00
        CBT vs ACT−0.210.19−1.140.26−0.200.08−2.500.01
      Abbreviations: ACT-D, acceptance and commitment therapy for depression; CBT-D, cognitive–behavioral therapy for depression; IPT, interpersonal psychotherapy; SE, standard error.
      Figure thumbnail gr2
      Figure 2Results of loess regressions showing reductions over time in suicidal ideation by treatment and gender.
      Repeating analyses within the female stratum, in contradistinction with results reported above for male patients, the Treatment × Wave interaction was not statistically significant, χ2 (4) = 3.41, p = .492. As with male veterans, wave-to-wave ideation severity based on LSM estimates decreased markedly over the course of therapy both across (Table 3) and within treatments (Table 3; Figure 2). Again mirroring effects observed among men, decreases in symptomology were most pronounced between the outset of therapy and its midpoint. Comparable percentage-wise decreases in suicidal ideation severity over the course of therapy for IPT, CBT-D, and ACT were 72.4%, 61.0%, and 55.4%, respectively.

      Responder Analyses

      Results of responder analyses were generally consistent with results of primary analyses. Rates of response among men differed across programs (Table 4). In subsequent bivariate comparisons between programs, the proportions of male responders in both IPT, χ2 = 5.63; p = .018, and CBT-D, χ2 = 7.82; p = .005, exceeded rates observed for veterans treated in ACT-D (Table 4); proportional differences in response levels between CBT-D and ACT-D programs did not differ significantly, χ2 = 0.07; p = .796. Among women, the rate of response did not differ significantly between programs. The proportions of female responders across programs were slightly higher relative to men but similar in pattern; however, as indicated by the omnibus test, above, χ2 = 3.798; p = .150, bivariate tests of proportional program differences between female responders failed to attain statistical significance. The lack of statistical significance between programs in part may reflect a type II error related to limited sample size. The proportion of responders among female participants across all programs exceeded the proportion of male responders across programs, although this difference was not statistically significant (54.7%–48.0%; χ2 = 3.73; p = .053). Within programs, the response rates for women treated within IPT exceeded levels observed in male participants by more than 14%, although the difference was not statistically significant (χ2 = 2.91; p = .088). Gender differences between veterans in the remaining two programs also did not differ significantly (Table 4; CBT-D: χ2 = 0.36; p = .548; ACT-D: χ2 = 1.39; p = .238).
      Table 4Treatment Responders
      ProgramMenWomen
      No ResponseResponseTotalsNo ResponseResponseTotals
      Program by gender
       IPT85 (47.5%)94 (52.5%)17915 (33.3%)30 (66.7%)45
       CBT-D229 (48.6%)242 (51.4%)47157 (45.6%)68 (54.4%)125
       ACT-D233 (58.1%)168 (41.9%)40144 (51.2%)42 (48.5%)86
       Totals5475041051116140256
      Contrastχ2pχ2p
      Overall9.6043.00823.7979.1497
      IPT vs CBT0.07.79612.04.1533
      IPT vs ACT5.63.01763.79.0514
      CBT vs ACT7.82.00520.63.4267
      IPTCBT-DACT-D
      No ResponseResponseTotalsNo ResponseResponseTotalsNo ResponseResponseTotals
      Gender by program
       Men85 (47.5%)94 (52.5%)179229 (48.6%)242 (51.4%)471233 (58.1%)168 (41.9%)401
       Women15 (33.3%)30 (66.7%)4557 (45.6%)68 (54.4%)12544 (51.2%)42 (48.8%)86
       Totals100124224286310596277210487
      Contrastχ2pχ2pχ2p
      Men vs women2.91.08780.36.5481.39.2382
      Abbreviations: ACT-D, acceptance and commitment therapy for depression; CBT-D, cognitive–behavioral therapy for depression; IPT, interpersonal psychotherapy.

      Attrition

      Associations between attrition at both waves 2 and 3 and veterans’ BDI-II item nine scores at the immediately preceding wave were nonsignificant, as were tests of wave 3 attrition based on wave 1–wave 2 difference scores. The tests were repeated using the full BDI-II measure as well as a set of available demographic covariates. In all instances, results were not statistically significant. Owing to the absence of any apparent systematic associations within variables present in the data, missing data were assumed to occur at random.

      Discussion

      Our findings in a large clinical sample of veterans participating in EBPs for depression found that CBT-D, IPT, and ACT-D each accomplished reductions in suicidal ideation, with decreases evident by treatment midpoint. These findings add to the emerging literature examining the impact of depression treatments on suicidal ideation. Although published findings on putative gender differences in treatment response for interventions targeting suicidal ideation are conflicting, these results describe greater decreases in the severity of suicidal ideation among women relative to men. These findings demonstrate that interventions with a strong evidence base for treating depression are concurrently effective in decreasing suicidal ideation among veterans and, as suggested, may be particularly effective in decreasing suicidal ideation in women veterans. Although women veterans showed sharper declines in suicidal ideation severity with treatment, responder analyses revealed that women were not more likely to evidence elimination of ideation relative to men.
      Owing to the limited available data comparing the effectiveness of ACT-D to other EBPs for depression in decreasing suicidal ideation (
      • Tighe J.
      • Nicholas J.
      • Shand F.
      • Christensen H.
      Efficacy of acceptance and commitment therapy in reducing suicidal ideation and deliberate self-harm: Systematic review.
      ), our finding that ACT-D was less effective in this analysis is novel. Furthermore, gender-stratified analyses demonstrated that this effect was largely driven by the poorer response of male veterans to ACT-D relative to IPT and CBT-D. It may follow that IPT and CBT-D are preferable treatments for male veterans reporting suicidal ideation; however, as previously suggested in a review (
      • Tighe J.
      • Nicholas J.
      • Shand F.
      • Christensen H.
      Efficacy of acceptance and commitment therapy in reducing suicidal ideation and deliberate self-harm: Systematic review.
      ), unequivocal evaluation of gender differences in treatment of depression and suicidality would require rigorous controlled trials with appropriate randomization of men and women across treatments (including ACT-D). Supporting this, a meta-analysis of ACT-D studies noted that studies with greater proportions of men were associated with larger effect sizes (
      • Öst L.G.
      The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis.
      ), thus indicating that design artifacts in outcomes related to depression warrant subgroup analysis by gender.

      Limitations

      The generalizability of these program evaluation findings is increased by the provision of the therapies by clinicians receiving training, the relatively few exclusions, and the use of routine clinical referral pathways to identify patients. Conversely, results are limited by the lack of experimental assignment to treatments and the unavailability of data concerning concurrent treatments and clinician factors that might have influenced changes in clinical outcomes. It must also be noted that clinicians received expert consultation during treatment provision, which does not reflect routine clinical practice. Additionally, although ACT-D was designed as a 12-session treatment, IPT and CBT-D protocols allowed up to 16 sessions of treatment, a difference in dose that may account for the greater decreases in symptoms experienced by men in IPT and CBT-D relative to ACT-D by the wave 3 measurement. Arguing against this supposition, it is noteworthy that differences were observed between ACT-D and both IPT and CBT-D among men by wave 2, indicating that differences were evident before differences in treatment dose. Veterans lost to follow-up and resulting missing data also present limitations, and conclusions cannot be drawn about the status of veterans without data at all waves.
      These results are further limited by the single-item measure of suicidal ideation used in the present analyses. Although BDI-II item nine has been shown to be a valid measure for assessing suicidal ideation (
      • Desseilles M.
      • Perroud N.
      • Guillaume S.
      • Jaussent I.
      • Genty C.
      • Malafosse A.
      • Courtet P.
      Is it valid to measure suicidal ideation by depression rating scales?.
      ), there are more optimal measures, and future work in this area would benefit from the use of a longer, more reliable assessment of suicidal ideation. The present results also cannot specify that any reduction in suicidal ideation evidenced through participation in EBPs for depression results in subsequent reduction in risk of suicidal behavior; thus, future research would benefit from longitudinal assessment of suicidal ideation and attempts. Finally, these conclusions are limited by a lack of data to characterize the factors associated with suicide risk beyond suicidal ideation, most notably any history of suicide attempts or psychiatric hospitalizations.

      Implications for Practice and/or Policy

      The results of this report support the effectiveness of EBPs for depression for decreasing suicidal ideation in veterans. They also support the inclusion of veterans experiencing suicidal ideation as a part of standard VHA clinician training aimed at promoting the generalization of clinician skills and increasing veterans’ access to EBPs for depression. We also note that these results provide particularly strong support for the effectiveness of EBPs for depression for reducing suicidal ideation in women veterans. Owing to the rising rate of suicide in women veterans (
      U.S. Department of Veterans Affairs (VA), Office of Mental Health and Suicide Prevention (OMHSP)
      Facts About Suicide Among Women Veterans: August 2017.
      ), greater lifetime prevalence of suicidal ideation and attempts among women (
      • Millner A.J.
      • Ursano R.J.
      • Hwang I.
      • King A.J.
      • Naifeh J.A.
      • Sampson N.A.
      • Nock M.A.
      Lifetime suicidal behaviors and career characteristics among U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
      ), and association of both depression (
      • Arsenault-Lapierre G.
      • Kim C.
      • Turecki G.
      Psychiatric diagnoses in 3275 suicides: A meta-analysis.
      ) and suicidal ideation (
      • Millner A.J.
      • Ursano R.J.
      • Hwang I.
      • King A.J.
      • Naifeh J.A.
      • Sampson N.A.
      • Nock M.A.
      Lifetime suicidal behaviors and career characteristics among U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
      ) with suicide among women, these findings provide a rationale for facilitating access to EBPs for depression in women veterans with depression. In addition, the relative advantages of IPT and CBT-D for reducing suicidal ideation in male veterans would perhaps argue for the initiation of strategies designed to tailor treatments for male veterans based on levels of pretreatment suicidal ideation and/or further analysis of gender differences based on more rigorous clinical trial formats as an entrée to matching the strategies suggested elsewhere in this article. Clinical guidance should also inform the role of EBPs for depression in reducing risk of suicide in the context of suicide-focused psychotherapies and other interventions employed in efforts to prevent suicide.

      Conclusions

      This program evaluation project provides the first comparison of the clinical effectiveness of three EBPs for depression for reducing suicidal ideation across male and female veterans. This analysis revealed that 1) all three EBPs for depression that were examined resulted in statistically significant reductions in suicidal ideation and reductions were evident by the midpoint of treatment; 2) women veterans reported greater decreases in suicidal ideation severity across all three EBP treatments; and 3) decreases in suicidal ideation were greater among male veterans treated in IPT or CBT-D relative to ACT-D.

      Acknowledgments

      The authors express their gratitude to the project staff and clinicians who collected data as part of the clinical care they provided to their patients. The authors thank the veterans who sought treatment for depression and provided data for this evaluation project.

      References

        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders (DSM-5®).
        American Psychiatric Publishing, Washington, DC2013
        • Arsenault-Lapierre G.
        • Kim C.
        • Turecki G.
        Psychiatric diagnoses in 3275 suicides: A meta-analysis.
        BMC Psychiatry. 2004; 4: 37
        • Beck A.T.
        • Steer R.A.
        • Brown G.K.
        Manual for the Beck Depression Inventory-II.
        TX: Psychological Corporation, San Antonio1996
        • Bockting C.L.
        • Spinhoven P.
        • Koeter M.W.
        • Wouters L.F.
        • Visser I.
        • Schene A.H.
        Differential predictors of response to preventive cognitive therapy in recurrent depression: A 2-year prospective study.
        Psychotherapy and Psychosomatics. 2006; 75: 229-236
        • Brown G.K.
        • Karlin B.E.
        • Trockel M.
        • Gordienko M.
        • Yesavage J.
        • Taylor C.B.
        Effectiveness of cognitive behavioral therapy for veterans with depression and suicidal ideation.
        Archives of Suicide Research. 2016; 20: 677-682
        • Cavanagh J.T.
        • Carson A.J.
        • Sharpe M.
        • Lawrie S.M.
        Psychological autopsy studies of suicide: A systematic review.
        Psychological Medicine. 2003; 33: 395-405
        • Cuijpers P.
        • Geraedts A.S.
        • van Oppen P.
        • Andersson G.
        • Markowitz J.C.
        • van Straten A.
        Interpersonal psychotherapy for depression: A meta-analysis.
        American Journal of Psychiatry. 2011; 168: 581-592
        • Curry J.F.
        • Aubuchon-Endsley N.
        • Brancu M.
        • Runnals J.J.
        • Fairbank J.A.
        Lifetime major depression and comorbid disorders among current-era women veterans.
        Journal of Affective Disorders. 2014; 152: 434-440
        • Davis T.D.
        • Campbell D.G.
        • Bonner L.M.
        • Bolkan C.R.
        • Lanto A.
        • Chaney E.F.
        • Rubenstein L.V.
        Women veterans with depression in Veterans Health Administration primary care: An assessment of needs and preferences.
        Women's Health Issues. 2016; 26: 656-666
        • Desseilles M.
        • Perroud N.
        • Guillaume S.
        • Jaussent I.
        • Genty C.
        • Malafosse A.
        • Courtet P.
        Is it valid to measure suicidal ideation by depression rating scales?.
        Journal of Affective Disorders. 2012; 136: 398-404
        • Evans C.
        Cognitive–behavioural therapy with older people.
        Advances in Psychiatric Treatment. 2007; 13: 111-118
        • Franklin J.C.
        • Ribeiro J.D.
        • Fox K.R.
        • Bentley K.H.
        • Kleiman E.M.
        • Huang X.
        • Nock M.K.
        Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research.
        Psychological Bulletin. 2017; 143: 187-232
        • Green K.L.
        • Brown G.K.
        • Jager-Hyman S.
        • Cha J.
        • Steer R.A.
        • Beck A.T.
        The predictive validity of the Beck Depression Inventory suicide item.
        Journal of Clinical Psychiatry. 2015; 76: 1683-1686
        • Harris E.C.
        • Barraclough B.
        Suicide as an outcome for mental disorders: A meta-analysis.
        British Journal of Psychiatry. 1997; 170: 205-228
        • Hayes S.C.
        • Levin M.E.
        • Plumb-Vilardaga J.
        • Villatte J.L.
        • Pistorello J.
        Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy.
        Behavior Therapy. 2013; 44: 180-198
        • Hofmann S.G.
        • Asnaani A.
        • Vonk I.J.
        • Sawyer A.T.
        • Fang A.
        The efficacy of cognitive behavioral therapy: A review of meta-analyses.
        Cognitive Therapy and Research. 2012; 36: 427-440
        • Holma K.M.
        • Haukka J.
        • Suominen K.
        • Valtonen H.M.
        • Mantere O.
        • Melartin T.K.
        • Isometsä E.T.
        Differences in incidence of suicide attempts between bipolar I and II disorders and major depressive disorder.
        Bipolar Disorders. 2014; 16: 652-661
        • Jarrett R.B.
        • Eaves G.G.
        • Grannemann B.D.
        • Rush A.J.
        Clinical, cognitive, and demographic predictors of response to cognitive therapy for depression: A preliminary report.
        Psychiatry Research. 1991; 37: 245-260
        • Karlin B.E.
        • Cross G.
        From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System.
        American Psychologist. 2014; 69: 19-33
        • Karlin B.E.
        • Brown G.K.
        • Trockel M.
        • Cunning D.
        • Zeiss A.M.
        • Taylor C.B.
        National dissemination of cognitive behavioral therapy for depression in the Department of Veterans Affairs health care system: Therapist and patient-level outcomes.
        Journal of Consulting and Clinical Psychology. 2012; 80: 707-718
        • Kessler R.C.
        • Berglund P.
        • Demler O.
        • Jin R.
        • Koretz D.
        • Merikangas K.R.
        • Wang P.S.
        The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R).
        JAMA. 2003; 289: 3095-3105
        • Krysinska K.
        • Batterham P.J.
        • Christensen H.
        Differences in the effectiveness of psychosocial interventions for suicidal ideation and behaviour in women and men: A systematic review of randomised controlled trials.
        Archives of Suicide Research. 2017; 21: 12-32
        • Maguen S.
        • Ren L.
        • Bosch J.O.
        • Marmar C.R.
        • Seal K.H.
        Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care.
        American Journal of Public Health. 2010; 100: 2450-2456
        • Markowitz J.C.
        • Weissman M.M.
        Interpersonal psychotherapy: Past, present and future.
        Clinical Psychology & Psychotherapy. 2012; 19: 99-105
        • McEvoy P.M.
        • Nathan P.
        Effectiveness of cognitive behavior therapy for diagnostically heterogeneous groups: A benchmarking study.
        Journal of Consulting and Clinical Psychology. 2007; 75: 344-350
        • Millner A.J.
        • Ursano R.J.
        • Hwang I.
        • King A.J.
        • Naifeh J.A.
        • Sampson N.A.
        • Nock M.A.
        Lifetime suicidal behaviors and career characteristics among U.S. Army soldiers: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
        Suicide and Life-Threatening Behavior. 2017; 48: 230-250
        • Nock M.K.
        • Hwang I.
        • Sampson N.
        • Kessler R.C.
        • Angermeyer M.
        • Beautrais A.
        • De Graaf R.
        Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys.
        PLoS Medicine. 2009; 6: e1000123
        • Nordentoft M.
        • Mortensen P.B.
        Absolute risk of suicide after first hospital contact in mental disorder.
        Archives of General Psychiatry. 2011; 68: 1058-1064
        • Öst L.G.
        The efficacy of acceptance and commitment therapy: An updated systematic review and meta-analysis.
        Behaviour Research and Therapy. 2014; 61: 105-121
        • Parker G.
        • Blanch B.
        • Crawford J.
        Does gender influence response to differing psychotherapies by those with unipolar depression?.
        Journal of Affective Disorders. 2011; 130: 17-20
        • Scott J.
        Cognitive therapy for depression.
        British Medical Bulletin. 2001; 57: 101-113
        • Seal K.H.
        • Metzler T.J.
        • Gima K.S.
        • Bertenthal D.
        • Maguen S.
        • Marmar C.R.
        Trends and risk factors for mental health diagnoses among Iraq and Afghanistan Veterans using Department of Veterans Affairs healthcare, 2002–2008.
        American Journal of Public Health. 2009; 99: 1651-1658
        • Spek V.
        • Nyklíček I.
        • Cuijpers P.
        • Pop V.
        Predictors of outcome of group and internet-based cognitive behavior therapy.
        Journal of Affective Disorders. 2008; 105: 137-145
        • Stewart M.O.
        • Raffa S.D.
        • Steele J.L.
        • Miller S.A.
        • Clougherty K.F.
        • Hinrichsen G.A.
        • Karlin B.E.
        National dissemination of interpersonal psychotherapy for depression in veterans: Therapist and patient-level outcomes.
        Journal of Consulting and Clinical Psychology. 2014; 82: 1201-1206
        • Sullivan H.S.
        The interpersonal theory of psychiatry.
        W. W. Norton & Co, New York1953
        • Thase M.E.
        • Reynolds C.F.
        • Frank E.
        • Simons A.D.
        • McGeary J.
        • Fasiczka A.L.
        • Garamoni G.G.
        • Jennings J.R.
        • Kupfer D.J.
        Do depressed men and women respond similarly to cognitive behavior therapy?.
        American Journal of Psychiatry. 1994; 151: 501
        • Tighe J.
        • Nicholas J.
        • Shand F.
        • Christensen H.
        Efficacy of acceptance and commitment therapy in reducing suicidal ideation and deliberate self-harm: Systematic review.
        Journal of Medical Internet Research. 2018; 5: e10732
        • U.S. Department of Veterans Affairs (VA), Office of Mental Health and Suicide Prevention (OMHSP)
        Facts About Suicide Among Women Veterans: August 2017.
        (Available:)
        • U.S. Department of Veterans Affairs (VA)
        VA National Suicide Data Report 2005-2015.
        (Available:)
        • U.S. Department of Veterans Affairs (VA), Office of Quality Safety and Value
        VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide.
        (Available:)
        • Walser R.D.
        • Sears K.
        • Chartier M.
        • Karlin B.E.
        Acceptance and commitment therapy for depression in veterans: Therapist manual.
        U.S. Department of Veterans Affairs, Washington, DC2012
        • Walser R.D.
        • Karlin B.E.
        • Trockel M.
        • Mazina B.
        • Taylor C.B.
        Training in and implementation of acceptance and commitment therapy for depression in the Veterans Health Administration: Therapist and patient outcomes.
        Behaviour Research and Therapy. 2013; 51: 555-563
        • Walser R.D.
        • Garvert D.W.
        • Karlin B.E.
        • Trockel M.
        • Ryu D.M.
        • Taylor C.B.
        Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in veterans.
        Behaviour Research and Therapy. 2015; 74: 25-31
        • Watson H.J.
        • Nathan P.R.
        Role of gender in depressive disorder outcome for individual and group cognitive–behavioral treatment.
        Journal of Clinical Psychology. 2008; 64: 1323-1337
        • Weissman M.M.
        • Markowitz J.C.
        • Klerman G.L.
        Comprehensive guide to interpersonal psychotherapy.
        Basic Books, New York2000
        • Weitz E.
        • Hollon S.D.
        • Kerkhof A.
        • Cuijpers P.
        Do depression treatments reduce suicidal ideation? The effects of CBT, IPT, pharmacotherapy, and placebo on suicidality.
        Journal of Affective Disorders. 2014; 167: 98-103

      Biography

      Mandy J. Kumpula, PhD, is Program Evaluator for the National Evidence-Based Psychotherapy Program within VA Office of Mental Health and Suicide Prevention and VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. Interests include mechanisms, effectiveness, and implementation of evidence-based psychotherapies.
      H. Ryan Wagner, PhD, is a Statistician and Data Scientist at the VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center and Associate Professor in the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine.
      Eric A. Dedert, PhD, is a Psychologist with the Durham VA Health Care System and VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. He is an Assistant Professor at Duke University. His interests include the clinical effectiveness of evidence-based treatments.
      Chris M. Crowe, PhD, serves as National Mental Health Director of Psychotherapy for the Veteran Healthcare Administration Office of Mental Health and Suicide Prevention.
      Kristine T. Day, PhD, is the National Evidence-Based Psychotherapy Program Manager within the Department of Veterans Affairs. Within this role, she oversees implementation, maintenance, monitoring, and evaluation of evidence based psychotherapy training programs within the VA.
      Kristin Powell, PhD, serves as National EBP Implementation Program Manager, VA Office of Mental Health and Suicide Prevention and VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. Professional interests include EBP training, implementation, and evaluation.
      Wendy H. Batdorf, PhD, is a clinical psychologist serving as the VA Evidence-Based Psychotherapy (EBP) Training Coordinator for the Cognitive Behavioral Therapy for Depression and Acceptance and Commitment Therapy for Depression Programs. Her professional interests include EBP training, depression, and geropsychology.
      Hani Shabana, PhD, is a clinical psychologist serving as the VA Evidence-Based Psychotherapy (EBP) Training Coordinator for the Interpersonal Psychotherapy for Depression and Cognitive Behavioral Therapy for Chronic Pain Programs.
      Ellie Kim, BA, is a psychology technician for the National Evidence-Based Psychotherapy Program within the Department of Veterans Affairs and the VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center.
      Nathan A. Kimbrel, PhD, is Research Psychologist and Assistant Director for Implementation Science and Program Evaluation at the Durham VA Medical Center and VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center. He is an Associate Professor at Duke University.