Concerns of Older Veteran Callers to the Veterans Crisis Line

When the Veterans Crisis Line (VCL) was implemented, it was uncertain if veterans, and particularly older male veterans, would utilize the service. We examined VCL use by a growing group of veterans at increased risk for suicide: those aged 60 and older. Real‐time clinical data were gathered from a weekly random sampling of calls. Approximately 25% of calls were from veterans aged 60 or older; over 80% reported benefit from the call. Several significant differences in presenting concerns between older and younger callers were found. Targeted outreach to encourage older veterans to use the VCL is suggested.     

Measuring Associations of the Department of Veterans Affairs' Suicide Prevention Campaign on the Use of Crisis Support Services

Campaigns have become popular in public health approaches to suicide prevention; however, limited empirical investigation of their impact on behavior has been conducted. To address this gap, utilization patterns of crisis support services associated with the Department of Veterans Affairs' Veterans Crisis Line (VCL) suicide prevention campaign were examined. Daily call data for the National Suicide Prevention Lifeline, VCL, and 1‐800‐SUICIDE were modeled using a novel semi‐varying coefficient method. Analyses reveal significant increases in call volume to both targeted and broad resources during the campaign. Findings underscore the need for further research to refine measurement of the effects of these suicide prevention efforts.     

Influences on Call Outcomes among Veteran Callers to the National Veterans Crisis Line

The association of caller and call characteristics with proximal outcomes of Veterans Crisis Line calls were examined. From October 1–7, 2010, 665 veterans with recent suicidal ideation or a history of attempted suicide called the Veterans Crisis Line; 646 had complete data and were included in the analyses. A multivariable multinomial logistic regression was conducted to identify correlates of a favorable outcome (a resolution or a referral) when compared to an unfavorable outcome (no resolution or referral). A multivariable logistic regression was used to identify correlates of responder‐rated caller risk in a subset of calls. Approximately 84% of calls ended with a favorable outcome, 25% with a resolution, and 59% with a referral to a local health care provider. Calls from high‐risk callers had greater odds of ending with a referral than without a resolution or referral, as did weekday calls (6:00 am to 5:59 pm EST, Monday through Friday). Responders used caller intent to die and the absence of future plans to determine caller risk. Findings suggest that the Veterans Crisis Line is a useful mechanism for generating referrals for high‐risk veteran callers. Responders appeared to use known risk and protective factors to determine caller risk.     

Drop-in suicide prevention group decreases suicidal ideation among Veterans

This study examined the effectiveness of a weekly, drop-in therapy support group designed for Veterans identified at increased risk for suicide. Veterans were identified as at risk for suicide and referred to the group following hospitalization on the inpatient psychiatric unit after an increase in suicidal ideation (SI), presentation to a provider with SI with a plan, or having made a suicide attempt. An archival chart review was performed on 359 patients who were referred to the Coping, Understanding, Support, and Prevention Group from 2009 through 2011. Documented risk of suicide was collected from the chart including: frequency of inpatient psychiatric hospitalization, visits to the emergency department or mental health walk in clinic for SI, reported SI in clinical notes, consults resulting from calls to the Veteran’s Crisis Line, and assignment or removal of suicide risk behavior flags in the electronic medical record, for a period of 12 months prior to referral to the group and for a period of 12 months after referral to the group. Negative binomial regression models found that Veterans attending the support group showed a significantly greater reduction in frequency of endorsing SI post-referral compared to those who did not attend the group. Results imply that offering Veterans an ongoing therapeutic group format to give and receive support from peers also struggling with suicide risk factors is an effective way to reduce suicide-related thoughts.     

Examination of potential disparities in suicide risk identification and follow-up care within the Veterans Health Administration

To improve the identification and intervention of suicide risk, the Veterans Health Administration implemented the use of electronic patient record flags (PRF) to indicate when a veteran is identified as high risk for suicide and to increase the clinical contacts made with the veteran. The current study utilized an intersectional approach to assess potential disparities in the likelihood of receiving a PRF and the likelihood of receiving post-PRF follow-up care among veterans with substance use disorders (SUDs). Among 458,092 veterans who received a SUD diagnosis in 2012, Black veterans were less likely to receive a PRF, although Black-disabled veterans and Black-female veterans were more likely to receive a PRF. Homelessness was related to greater likelihood of receiving a PRF and post-PRF care. Hispanic/Latinx veterans who experienced homelessness were more likely to receive post-PRF care, while disabled veterans who experienced homelessness were less likely. Hispanic/Latinx, female veterans, and Black-disabled veterans were significantly less likely to receive post-PRF care. Overall, few marginalized or intersecting identities were associated with decreased PRF or decreased follow-up care. There are opportunities for specific strategies that promote engagement in VA follow-up services for veterans identifying as Hispanic/Latinx women, disabled Black veterans, and disabled homeless veterans.     

A Systematic Review of Suicide Prevention Programs for Military or Veterans

Military personnel and veterans have important suicide risk factors. After a systematic review of the literature on suicide prevention, seven (five in the U.S.) studies of military personnel were identified containing interventions that may reduce the risk of suicide. The effectiveness of the individual components was not assessed, and problems in methodology or reporting of data were common. Overall, multifaceted interventions for active duty military personnel are supported by consistent evidence, although of very mixed quality, and in some cases during intervals of declines in suicide rates in the general population. There were insufficient studies of U.S. Veterans to reach conclusions.     

Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk?

In response to high suicide rates among veterans, the Department of Veterans Affairs (VA) has mandated that veterans at risk for suicide be given Safety Plans (SP). Research on the efficacy of SPs, however, is unclear and no prior study has examined the degree to which more personally relevant (i.e., higher quality) SPs may be associated with better outcomes or evaluate which components of SPs may be most effective at reducing suicidal behavior. The goal of the present study was to examine whether more personally relevant (i.e., higher quality) SPs reduce future suicide-related outcomes (psychiatric hospitalization, self-harm, and suicide attempts), and to determine which components of a SP may be most effective at reducing these outcomes. Participants were 68 individuals enrolled in a longitudinal national registry of returning military veterans receiving care from the VA, and who had at least one suicide-related event in the VA Suicide Prevention Applications Network. Data were collected between December 2009 and September 2016 and were analyzed between March 2016 and February 2017. Scores of SP quality were used to predict suicide-related outcomes. SP quality was low. Higher SP quality scores predicted a decreased likelihood of future suicide behavior reports (note entered into veteran’s chart after a report of any self-harm behavior, including a suicide attempt). Higher scores on Step 3 (people and places that serve as distractions) predicted a decreased likelihood of future suicide behavior reports. More personally relevant SPs may reduce future suicide-related outcomes among veterans. Low SP quality scores highlight the need for training around SP implementation in the VA.     

Spirituality and Religion: Neglected Factors in Preventing Veteran Suicide?

The Clay Hunt Suicide Prevention for American Veterans Act, enacted in 2015, aimed to increase access to treatment for U.S. military veterans; however, poor attendance at aftercare and high rates of treatment refusal suggest that, even when treatment is accessible, it may not be acceptable. Often, it is difficult to acknowledge the need for help and to commit to treatment. The stigma of mental illness diminishes the self-respect of individuals with mental health problems and may be especially acute for veterans because of the centrality of resilience in military culture. This stigma also can jeopardize current employment or prospects for future employment. This paper proposes a partial answer to the question, “What more might be done to engage and effectively treat veterans who are at high risk of suicide?” The meaning of spiritual and/or religious expression in human development, well-being, and social functioning has long been of great interest to theorists in disciplines as diverse as sociology, theology, and psychology. Some empirical studies have further suggested that certain religious and/or spiritual beliefs, practices, and/or affiliations may be protective against suicide. This paper (a) summarizes these perspectives, (b) considers how clinical inquiry into the role of religion and/or spirituality in the lives of veterans at high risk of suicide fits into the suicide prevention program of the U.S. Department of Veterans Affairs, and (c) offers specific recommendations to practitioners.     

Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among veterans receiving mental health services

History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.     

Intervening on Thwarted Belongingness and Perceived Burdensomeness to Reduce Suicidality Among Veterans: Subanalyses From a Randomized Controlled Trial

Suicide is a growing public health crisis among military veterans. Despite recent attention to this area, there are few empirically supported preventative interventions for suicidality among veterans. In the context of an empirically supported theoretical framework, the Interpersonal Theory of Suicide, the current study targeted suicide risk factors (i.e., perceived burdensomeness and thwarted belongingness) among a sample of 46 veterans selected from a larger clinical trial. Participants were randomized to receive either a newly developed computerized intervention aimed at decreasing perceived burdensomeness and thwarted belongingness, or participate in a repeated contact control condition. Results indicated a direct effect of the intervention on both perceived burdensomeness and thwarted belongingness. Temporal mediation analyses also revealed an indirect effect of condition on suicidality at Month 1 follow-up via reductions in perceived burdensomeness. The current results are the first to indicate that factors from the interpersonal theory of suicide can be reduced among veterans, and to demonstrate that these reductions in perceived burdensomeness lead to reductions in suicidality. Because of the brevity and computer delivery system, this intervention could be widely and rapidly disseminated among military veterans to reduce the public health burden of suicide in this population.     

Severe pain predicts greater likelihood of subsequent suicide

Using data from the 1999 Large Health Survey of Veterans, Veterans Affairs' medical records, and the National Death Index (N = 260,254), the association between self-reported pain severity and suicide among veterans as examined, after accounting for demographic variables and psychiatric diagnoses. A Cox proportional hazards regression demonstrated that veterans with severe pain were more likely to die by suicide than patients experiencing none, mild, or moderate pain (HR: 1.33; 95% CI: 1.15, 1.54), after controlling for demographic and psychiatric characteristics. These results indicate that pain evaluations should be included in comprehensive suicide assessments and suicide prevention efforts.     

Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow‐up (n = 168; 57%). Fifty‐three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.     

Suicide Exposure and Posttraumatic Stress Disorder: Is Marriage a Protective Factor for Veterans?

Alarming numbers of military veterans end their lives each day which has a profound effect on the military population. This study examines a sample (N?=?434) of suicide-exposed (i.e., personally knowing someone who has died by suicide) veterans to determine whether the proportion of individuals who report high impact from suicide exposure and those who have clinically-significant posttraumatic stress disorder symptoms is related to marital status. Using Hill’s (Social Casework 49: 139–150, 1958) ABC-X model for conceptualizing the relationships between variables, mean scores for posttraumatic stress disorder were significantly different between groups, and the odds of a married veteran reporting high-impact suicide exposure were 2.19 times lower than the odds of a single veteran reporting high-impact. Likewise, the odds of a veteran with high-impact suicide exposure having clinically-significant posttraumatic stress disorder symptoms were 10.04 times higher than veterans with low-impact suicide exposure. Findings indicate that veterans who are married are less likely to be highly-affected by another individual’s suicide. Thus, marriage is a protective factor for suicide-exposed veterans.     

A Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska: A Methodological Caveat

This study explored differences between homeless male veterans in metropolitan and micropolitan cities in Nebraska on sociodemographic, housing, clinical, and psychosocial characteristics as well as health service use. A convenience sample of 151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska. Research staff conducted structured interviews with homeless veterans. Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction. Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services. Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another. Many homeless veterans in these areas are transient, making them a difficult population to study and serve. Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed.     

Characteristics and VA health care utilization of U.S. Veterans who completed suicide in Oregon between 2000 and 2005

Oregon Violent Death Reporting System data were linked with Veterans Affairs (VA) administrative data to identify and describe veterans who completed suicide in Oregon from 2000 to 2005 (n = 968), and to describe their VA health care utilization in the year prior to death. Twenty-two percent had received health care in the VA system. Of these, 57% did not have mental health diagnoses and 58% had not seen mental health professionals. A larger proportion of those who accessed care were VA-enrolled and received service-connected disability benefits. Fifty-five veterans were hospitalized during the year prior to death. Of these, 33% completed suicide within 30 days of a hospitalization. Further development of suicide prevention strategies for veterans in the community, including general medical treatment settings, is indicated.     

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide‐specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self‐reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence‐based components—entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre‐suicidal mental state, regardless of their self‐reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.     

The Decline of Youth Suicidal Behavior in an Urban,Multicultural Public School System Following the Introduction of a Suicide Prevention and Intervention Program

A 5-year longitudinal study of suicidal behavior of students attending Dade County Public Schools (DCPS) in Miami, Florida, between the 1989–1990 and 1993–1994 school years, is described. As the fourth largest public school system in the United States, DCPS is representative of an urban, multicultural community. The prevalence of suicidal behavior among DCPS students necessitated the development of a districtwide Suicide Prevention and School Crisis Management Program (SPSCMP), including the creation of the “Youth in Crisis Hotline.” A review of eight national school districts' suicide prevention and intervention programs indicates similarities with the DCPS model. Statistical data compiled by the DCPS program are organized into annual, monthly, grade level, and school level classifications, and are analyzed to determine the degree and direction of self-destructive behavior among youth in a culturally and linguistically diverse school population following the introduction of a suicide prevention and intervention program. Evaluative data regarding the effectiveness of the program as well as implications for suicide prevention and intervention are discussed.     

Predictors of Suicide‐Related Hospitalization among U.S. Veterans Receiving Treatment for Comorbid Depression and Substance Dependence

This study examined whether widely accepted suicide risk factors are useful in predicting suicide-related hospitalization, beyond history of a suicide attempt, in high-risk treatment-seeking veterans with depression and substance dependence. Negative mood regulation expectancies were the only significant predictor of hospitalization during 6-months of outpatient treatment. History of a suicide attempt was the only significant predictor of hospitalization during the one-year follow-up period. Results suggest that within high-risk populations, standard suicide risk factors may not identify individuals who will engage in suicidal behaviors resulting in hospitalization. Assessing negative mood regulation expectations may assist in identifying those most at risk.     

Characteristics of Telephone Crisis Hotline Callers with Suicidal Ideation in Japan

Hotline callers do not always have suicidal ideation and previous studies have noted that the rate of such callers is limited. Crisis hotline counselors must be able to identify high‐risk callers in order to provide appropriate support. This study investigated the characteristics of Japanese crisis hotline callers in 2012 (N = 541,694) and is the first to analyze crisis hotline data for all parts of Japan over 1 year. About 14% of the callers had suicidal ideation and 6% had a history of attempted suicide. The odds ratio for suicidal ideation among those with a history of attempted suicide was 15.5. The suicidal ideation rate was much smaller compared to previous studies in other countries. There is a psychological barrier that must be broken for high‐risk people to use support hotlines. In addition, attempted suicide is a strong exclusive predisposing factor for death due to suicide; therefore, counselors should pay careful attention to callers with a history of attempted suicide. The characteristics of Japanese crisis hotline callers and the features of suicidal ideation revealed in the present study are expected to be useful in developing telephone crisis hotline strategies.     

An Innovative Approach to Treating Combat Veterans with PTSD at Risk for Suicide

Suicide rates among military personnel had a significant drop in 2013, but there is no evidence of a drop among veterans. The problem of suicide among combat veterans with posttraumatic stress disorder (PTSD) remains a source of concern. The Department of Defense and the Department of Veterans Affairs are now calling for innovative treatment approaches to the problem. A short‐term psychodynamic therapy presented here may be able to fill that need by dissipating the guilt from veterans' combat‐related actions that leads to suicidal behavior. The treatment showed promise of success with veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates that it may be equally successful in treating them. Basic aspects of the psychodynamic approach could be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide.