Effects of Neuromodulation and Cognitive Training for Suicide in Veterans (ENACTS)

Impaired executive function, such as impaired decision making and impulsivity, has been identified as an important contributor to the transition from suicidal ideation to suicide attempt. To address the epidemic of Veteran suicide in the United States, we propose to test the feasibility, acceptability, and preliminary

effectiveness of a five day transcranial direct current stimulation (tDCS) augmented executive functioning training intervention. This intervention will be delivered to high suicide risk inpatients who have been hospitalized following a suicide attempt. The ultimate goal is to reduce future suicide events (ideation,

attempts, deaths) and improve quality of life (e.g. social relationships, health resource utilization). Our intervention combines two existing interventions: tDCS and cognitive training. tDCS is a simple, low cost, easy to use non-invasive neuromodulation technology demonstrated to enhance brain plasticity and accelerate

learning. Executive function training is a proven intervention that improves executive functioning in clinical populations. When tDCS and executive function training are combined, learning rate, executive functioning, and transfer to other functions is improved compared with executive function training alone.

We propose to test the feasibility and acceptability of a five day intervention consisting of ten sessions of tDCS augmented executive function training in a high suicide risk population: Veterans admitted to a hospital following a suicide attempt. Inpatients have the highest risk of suicide attempts within the initial weeks following

discharge with 50% occuring within 12 weeks of discharge. This suggests that the time prior to hospital discharge could be a critical intervention period. Additionally, we will collect longitudinal and daily real-time data on help-seeking, suicide risk, and related factors in the month after discharge using Ecological Momentary

Assessment (EMA). Given that help-seeking and suicide risk fluctuate during the week, EMA offers an improvement over existing research that relies on retrospective and cross-sectional methods. Our Aims are: Aim 1: Determine feasibility and acceptability of the tDCS augmented executive function training intervention.

Feedback will be obtained from patients and clinical staff through questionnaires, interviews, and debriefs to examine their experience and satisfaction with the intervention and study methods. We will also use participants’ performance data to assess engagement with, and ease of use of, the training exercises.

Aim 2: Assess preliminary effects of the intervention on 1) the behavioral treatment target of executive functioning, and 2) reduction in suicide events (ideation, attempts, deaths) and improvement in quality of life. Variability and precision estimates (95% confidence intervals) will be calculated.

Aim 3: Explore between- and within-person variability of cognitive factors (executive function task performance), help-seeking, and suicidal thinking and behavior in the one month post-discharge via in-person visits and daily Ecological Momentary Assessment (EMA). Significance. Reducing Veteran suicide has been the top clinical priority of the VA for the last few years.

However, the total number of suicides among Veterans has continued to increase. There is a critical need for targeted treatments to reduce the risk of suicide in Veterans. The low cost, simplicity, and safety of this

intervention makes it easy to deliver and scale to clinical settings. If this pilot trial is successful, it would set the stage for a larger trial to test the effectiveness of this intervention for reducing suicide events in a high suicide risk population.