Research and Evidence-based Approaches

The Need

The Objective Zero Foundation addresses the social problem of suicide within the military community. Specifically, the Objective Zero App connects community members to peer support, provides access to health and wellness tools, training, and resources, and uses push notification technology to provide resources and caring messages to its users. 

Approximately 17.2 service members and veterans die by suicide every day, a rate that is nearly 1.5 times that of their civilian counterparts. While there is no single cause of suicide, there are a number of risk factors that contribute to it, including unemployment, poverty, homelessness, lack of social connection, access to lethal means, barriers to treatment, and general health and well-being (most notably, alcoholism). Stigma is a significant barrier to veterans and active service members getting the support they need. In fact, 60% of military personnel who experience mental health problems do not seek treatment.  Research on The Hemingway Effect suggests that military members who are at the highest risk of suicide are those who have seen combat, are retiring or reaching the end of active duty, or are older veterans reaching late life.

Approach

Numerous studies have explored the complex nature of and potential solutions to the suicide epidemic within the military community. Three theories help us understand the complexities are:

• Conservation of Resources Theory (COR)

• Military Transition Theory

• Hemingway Effect Theory 

Objective Zero’s model incorporates components of each of these theories into its mobile app, which connects military members and veterans to peer support. A wealth of research supports using moble apps and peer-based approaches to prevent suicide and promote mental health. 

The App

Objective Zero combines mobile technology with support from volunteers to deliver wellness and mental health resources to veterans and active servicemembers. The National Institute of Mental Health (NIMH) has pointed to mental health apps as cost-effective and scalable solutions to address the mental health treatment gap. They suggest that mobile apps have significant potential to deliver high-efficacy mental health interventions, especially given the global shortage of psychiatrists and the lack of care in rural areas, apps have emerged as a viable tool. 

This is supported by an additional study published in Frontiers in Psychology, which found that less than one-third of suicidal individuals seek help, due to stigma, shame, and a preference for self-management. This same study supports the concept of using mobile apps as a more accessible, less costly, and more confidential alternative to traditional means of treatment. 

Several additional advantages of using mobile apps for monitoring mental health are indicated within the research: 1) improvement of treatment accessibility and participant retention, 2) opportunity for real-time symptom and activity monitoring and tracking of progress, 3) provision of personalized feedback and motivational support, 4) portability and flexibility of use, and 5) potential to improve adherence to treatment. 

Finally, research suggests that an important component of suicide prevention strategies are crisis helplines, which provide timely and anonymous advice to callers at risk of suicide and are effective in deterring active suicidal thoughts. The Objective Zero App provides an opportunity to connect immediately with a Pathfinder who can offer support much like a helpline and can also connect a user to a helpline staffed by professionals.

Peer Support

Objective Zero utilizes peer and civilian support Pathfinders to deliver its programming. As Co-Founder Chris Mercado says “We believe veteran suicide can be prevented through the simple act of listening.” Research demonstrates that peer supporters may improve connectedness by providing emotional support, decreasing loneliness and stigma, and facilitating improved relationships with others. Peer support has its roots in mental health and substance abuse treatment and has gained recognition in almost every sector of healthcare since the 1970s. 

Research on peer support is still in its infancy but many studies have revealed positive results in terms of social connectedness, health, and quality of life. One of the most influential factors for overcoming barriers to seeking care for military members was having family and friends strongly encourage soldiers to get help. Research suggests that social support could explain how service members and veterans who are disinclined to seek help subsequently access important services.

Outcomes

The intended outcomes of the Objective Zero approach for our users include:

• Improved sense of wellbeing,

• Increased sense of community,

• Reduced barriers to care,

• Increased resilience among the military and veteran community,

• Decreased rates of veteran and military suicide.

  Interested in becoming a Pathfinder? Click here to find out more!

Suicide prevention for high-risk persons who refuse treatment

Jerome A. Motto, M.D.

First Published Winter 1976, available at https://doi.org/10.1111/j.1943-278X.1976.tb00880.x

Abstract: A program was developed to exert a suicide prevention influence on high‐risk persons who decline to enter the health care system. There were 3,006 patients admitted to a psychiatric in‐patient service because of a depressive or suicidal state who were contacted to determine if the post‐discharge plan was followed. Half of those who refused their treatment program were contacted by telephone or letter on a set schedule. The contact was limited to expressing interest in the person's well‐being. Mortality in the contact group was compared with the no‐contact subjects and with the subjects who had accepted treatment, after 1, 2, 3, and 4 years. Suicidal deaths were found to diverge progressively in the three groups, the treatment subjects showing the highest rates, the no‐contact group coming next, and the contact subjects showing the lowest. The observed divergence between the contact and no‐contact groups provides tentative evidence that a high‐risk population for suicide can be identified and that a systematic approach to reducing that risk can be applied.

A randomized controlled trial of post-crisis suicide prevention

Jerome A. Motto, M.D. and Alan G. Bostrom, Ph.D.

Published June, 2001 in Psychiatric Services, vol. 52, No. 6.

Objective: This study tested the hypothesis that professionals’ maintenance of long-term contact with persons who are at risk of suicide can exert a suicide-prevention influence. This influence was hypothesized to result from the development of a feeling of connectedness and to be most pertinent to high-risk individuals who refuse to remain in the health care system. Methods: A total of 3,005 persons hospitalized be- cause of a depressive or suicidal state, populations known to be at risk of subsequent suicide, were contacted 30 days after discharge about fol- low-up treatment. A total of 843 patients who had refused ongoing care were randomly divided into two groups; persons in one group were con- tacted by letter at least four times a year for five years. The other group—the control group—received no further contact. A follow-up procedure identified patients who died during the five-year contact pe- riod and during the subsequent ten years. Suicide rates in the contact and no-contact groups were compared. Results: Patients in the contact group had a lower suicide rate in all five years of the study. Formal survival analyses revealed a significantly lower rate in the contact group (p=.04) for the first two years; differences in the rates gradually diminished, and by year 14 no differences between groups were observed.Conclusions: A systematic program of contact with persons who are at risk of suicide and who refuse to remain in the health care system appears to exert a significant preventive influence for at least two years.

Effect of Augmenting Standard Care for Military Personnel With Brief Caring Text Messages for Suicide Prevention: A Randomized Clinical Trial

Katherine Anne Comtois, PhD, MPH1; Amanda H. Kerbrat, MSW1; Christopher R. DeCou, PhD1; David C. Atkins, PhD1; Justine J. Majeres, PsyD2; Justin C. Baker, PhD3; Richard K. Ries, MD1

JAMA Psychiatry. Published online February 13, 2019. doi:10.1001/jamapsychiatry.2018.4530

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. 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. Primary outcomes were current suicidal ideation and suicide risk incidents. 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. 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.