0930-0333 Iminent Risk SS-B_4_23_15

the networking suicide prevention hotlines—Evaluation of imminent risk

Supporting Statement

B. Statistical Methods

B1. Respondent Universe and Sampling Methods

There are over 160 crisis centers in the Lifeline network. This evaluation is designed to identify and work with eight of those centers. Centers will be selected to represent a cross-section of the Lifeline network. Eligible calls will include those involving imminent risk, as identified by individual counselors using the Lifeline Policies and Guidelines for Helping Callers at Imminent Risk of Suicide. The determination of the necessity of surveying eight centers results from our intentions to extend and replicate findings from our earlier data collection involving eight centers.

The eight new centers will be selected based on their responses to the Lifeline’s 2015 Crisis Center Survey. Criteria will include center size, call volume, region, urban vs. rural location, whether staffed primarily by paid staff or volunteers, and whether or not the call center is embedded within a larger community mental health organization. The goal will be to select centers which are broadly representative of the diversity of Lifeline crisis centers overall. The results should therefore be reflective of helper practices across the Lifeline as a whole. All analyses will use nesting within center to account for the impact of center differences on our results.

Also based on centers’ responses to Lifeline’s 2015 Crisis Center Survey, SAMHSA plans to select only centers which have not made regular use of the Lifeline’s online simulation training for crisis helpers (the “Lifeline Simulation Training System.”) Lifeline has informed us of their plan to actively promote the Lifeline Simulation Training System in the near future. By selecting centers which are not already exposed to the training prior to this upcoming promotion effort, SAMHSA anticipate that our sample will include sufficient variability in counselors’ exposure to this training to allow us to examine its impact on counselors’ interventions.

Counselors within the centers will not be selected. All counselors responsible for answering crisis calls at each center are eligible for study participation. All counselors who answer at least one call from a caller s/he considers to be at imminent risk of suicide during the data collection period will be included. During our previous data collection, 266 counselors across eight centers were eligible for participation, but only 132 answered at least one call from an imminent risk caller during the study period and thus had the opportunity to complete our Imminent Risk Questionnaire. This is the basis of our estimate of 132 participating counselors across the eight new centers.

Each counselor will submit one Imminent Risk Questionnaire for each imminent risk call s/he handles during the study period. SAMHSA will not assess changes in an individual counselor’s adherence to the Guidelines over time. If a counselor reports additional training during our data collection period (e.g., in ASIST, Safety Planning, or the Lifeline Simulation Training ), our analyses will take this into account by coding that counselor as untrained on calls handled prior to his/her new training, and as trained on calls handled subsequent to his/her new training. This information will be used when analyzing the relationship between training status and interventions used with imminent risk callers. It will not be used to measure changes in an individual counselor’s behavior over time. Therefore, our analytic plan does not include a pre- and post-evaluation of selected counselors.

The estimation of statistical power was based on the number of calls not the number of counselors or the number of centers. Because of the relative infrequency of imminent risk calls, and based on our earlier experiences, SAMHSA estimates that 8 centers will be needed to generate a sufficient number of calls/forms across the three-year period. Moreover, in estimating statistical power SAMHSA used a variance inflation factor (VIF= 1.06) to account for correlation within centers and counselors. As noted in our Supporting Statement Section A, combining the data collected during our previous evaluation with the data collected during our proposed evaluation (combined N=1240 imminent risk forms) should provide adequate statistical power for our quantitative analyses For example, assuming 79% of all counselors complete safety plan training, SAMHSA will have 80% power to detect a voluntary rescue rate difference between 25% (without safety plan training) and 17% (with safety plan training). Understanding how counselors determine if a caller is at imminent risk will be based on a qualitative analysis of the open-ended responses in; as such, there is no power analysis associated with this qualitative analysis.

B2. Information Collection Procedures

Data for the evaluation will be collected during imminent risk calls to the eight participating crisis centers. The National Suicide Prevention Lifeline—Imminent Risk Form-Revised was developed to ensure standardized data collection across sites. Crisis counselors at each participating center will be asked to complete the Imminent Risk Form-Revised for every imminent risk caller to their centers across a 3-year period. Counselors will be trained by the evaluation staff via telephone to complete the form. Counselors may complete the form in hard copy via fax or enter the information into an online survey and submit. Counselors will have been trained by their centers in the Lifeline Policies and Guidelines for Helping Callers at Imminent Risk of Suicide prior to participating in the evaluation. The counselor will not ask the caller questions from the form, but will complete the form after the call based on the information discussed with the caller for clinical purposes.

Table 3 summarizes the information collection procedures for the imminent risk form.

Table 3. Procedures for the Collection of Information

National Suicide Prevention Lifeline—Imminent Risk Form-Revised
Indicators (Center) Types of crisis services offered by center Availability of mobile crisis team Characteristics of mobile crisis team	Indicators (Imminent Risk Call) Demographic information of the imminent risk caller Line called (Lifeline or center line) Language spoken Whether a third party initiated or joined call If person is repeat caller (if known) Ratings on the suicidal desire and suicidal intent of person at imminent risk Suicidal capability and history of risk behaviors (e.g., prior suicide attempt, violence, substance abuse, sleep problems) Protective factors/buffers (e.g., social supports, sense of purpose) Intervention type either undertaken by caller (e.g., take actions on his/her own behalf to immediately reduce imminent risk, get rid of lethal means) or undertaken by counselor with or without caller’s consent (e.g., send public safety officials for safety check, send mobile crisis unit) Interventions involving participating third party (if any) Barriers to getting help for person at imminent risk Steps taken to confirm whether emergency contact was made Outcome of attempts to rescue person at imminent risk Outcome of attempts to follow up on case
Data Source(s): One counselor/center
When Collected: One time prior to first imminent risk call
Indicators (Counselor) Employment status of counselor Counselor start date Average number of hours per week Average number of weekly suicide calls Level of education Licensure status ASIST training status Simulation training status Other safety planning training status Sources of protocols used Follow up responsibilities
Data Source(s): Counselors	Data Source(s): Counselors handling imminent risk calls
When Collected: One time following first imminent risk call	When Collected: For each imminent risk call to the crisis hotline after the call has been completed

B3. Methods to Maximize Response Rates

The National Suicide Prevention Lifeline—Imminent Risk Form-Revised will be implemented by all counselors in each of the eight centers as part of their job responsibilities. It is expected that counselors will complete imminent risk forms for 100% of callers who are at imminent risk for suicide. Initial questions about counselor training and experience will be completed only once.

B4. Tests of Procedures

The National Suicide Prevention Lifeline—Imminent Risk Form-Revised has been reviewed by experts in the fields of suicide prevention and mental health and piloted to determine burden levels.

B5. Statistical Consultants

The evaluator has full responsibility for the development of the overall statistical design and assumes oversight responsibility for data collection and analysis for the evaluation. Training and monitoring of data collection will be provided by the evaluator. The following individuals are primarily responsible for overseeing data collection and analysis:

Madelyn S. Gould, Ph.D., M.P.H.

Professor,

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5329

Jimmie Lou Munfakh, B.A.

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5482

Marjorie Kleinman, M.S.

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-5959

Alison Lake, M.A.

Psychiatry and Public Health (Epidemiology)

Columbia University/NYSPI

1051 Riverside Drive, Unit 72

New York, NY 10032

212-543-6714

Hanga Galfalfy, Ph.D.

Associate Professor of Biostatistics (in Psychiatry),

Columbia University/NYSPI

1051 Riverside Drive, 

New York, NY 10032

646-774-5460

The SAMHSA project officer responsible for receiving and approving deliverables is:

Richard McKeon, Ph.D.

Center for Mental Health Services

SAMHSA

1 Choke Cherry Road, Room 6-1105

Rockville, MD 20857

240-276-1873

References

Gould, M. S., Cross W., Pisani A. R., Munfakh J. L., & Kleinman M. (2013) Impact of applied suicide intervention skills training on the National Suicide Prevention Lifeline. Suicide and Life Threatening Behavior, 43(6), 676–691.

Gould, M. S., Munfakh, J. L. H., Kleinman, M., & Lake, A. M. (2012). National Suicide Prevention Lifeline: Enhancing mental health care for suicidal individuals and other people in crisis. Suicide and Life-Threatening Behavior, 42(1), 22–35.

Gould, M.S., & Kalafat, J. (2009). Crisis hotlines. In Oxford Textbook of Suicidology and Suicide Prevention—A (pp. 459–462). Oxford, UK: Oxford University Press.

Gould, M.S., Kalafat, J., Harris–Munfakh, J.L., and Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 2: Suicidal callers. Suicide and Life–Threatening Behavior, 37(3), 338–352.

Kalafat, J., Gould, M.S., Harris–Munfakh, J.L., and Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 1: Nonsuicidal crisis callers. Suicide and Life–Threatening Behavior, 37(3), 322–337.

King, R., Nurcombe, R., Bickman, L., Hides, L. & Reid, W. (2003). Telephone counseling for adolescent suicide prevention: Changes in suicidality and mental state from beginning to end of a counseling session. Suicide and Life Threatening Behavior, 33(4), 400-411.

Knox, K. L., Kemp, J., McKeon, R., & Katz, I. R. (2012). Implementation and early utilization of a suicide hotline for veterans. American Journal of Public Health, 102(Suppl. 1), S29–S32.

Mishara, B. L., Chagnon, F., Daigle, M., Balan, M., Raymond, S., Marcoux, I., … Berman, A. (2007a). Which helper behaviors and intervention styles are related to better short term outcomes in telephone crisis intervention? Results from a silent monitoring study of calls to the U.S. 1-800-SUICIDE Network. Suicide and Life Threatening Behavior, 37(3), 291–307.

Mishara, B. L., Chagnon, F., Daigle, M., Balan, M., Raymond, S., Marcoux, I., … Berman, A. (2007b). Comparing models of helper behavior to actual practice in telephone crisis intervention: A silent monitoring study of calls to the U.S. 1-800-SUICIDE Network. Suicide and Life Threatening Behavior, 37(3), 308–321.

Substance Abuse and Mental Health Services Administration. (2011). Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014. HHS Publication No. (SMA) 11-4629. Rockville, MD: SAMHSA.

Attachment

Attachment 1: National Suicide Prevention Lifeline—Imminent Risk Form

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