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September is National Suicide Prevention Awareness Month

Spotlight on Suicide Prevention Research

September 2020


September is National Suicide Prevention Awareness Month and an important time to shed light on the toll that suicide takes—particularly on our nation’s Veterans. Among the general population, suicide has been steadily rising since 2005, and while Veterans comprise 8% of the US population, they account for 14% of deaths by suicide. Veterans between the ages of 18 and 29, those who are older than 60, and those living in rural communities are at the highest risk for suicide. Veterans’ access to and familiarity with firearms also pose a concern, as they were the method of suicide in 71% of male Veteran suicide deaths and 43% of female Veteran suicide deaths in 2017.1

Preventing suicide is one of VA’s highest priorities, and research that builds evidence-based suicide prevention policy and clinical practice is critical. VA’s Health Services Research & Development Service (HSR&D) investigators are conducting an extensive number of investigations designed to improve suicide prevention efforts for Veterans. This month’s spotlight features the following completed and ongoing studies into suicide prevention.

Randomized Evaluation of a Caring Letters Suicide Prevention Campaign


The rates of suicide among Veteran Crisis Line (VCL) callers are much higher than among other Veterans. Since callers may not be in mental health treatment, or even be connected to VA, outreach and evidence-based interventions are vital. Caring Letters for Suicide Prevention is an evidence-based intervention that has been tested since the 1970s, and is currently one of only two suicide prevention strategies that have reduced suicide rates in a randomized controlled trial. Investigators with VA’s Quality Enhancement Research Initiative (QUERI) are currently implementing a Caring Letters intervention in partnership with several of VA’s Integrated Service Networks, and results from this QUERI partnered evaluation program should inform potential improvements for large-scale implementation.

About the Study

Using the QUERI implementation framework and rigorous data analysis, investigators will evaluate the Caring Letters intervention against several main outcomes:

  • incidence of VA-documented suicide attempts;
  • incidence and frequency of VA psychiatric hospitalization, all-cause mortality, rates of suicide, rates of engagement in VA healthcare (in general); and
  • outpatient mental health utilization rates.

In addition, investigators expect to answer important operational questions, such as the effects of Caring Letters on a new population, as well as identify barriers and facilitators to program implementation and sustainability.

A key aspect of this evaluation will be Veteran engagement and input in the project design, as well as qualitative evidence such as key informant interviews to gather Veteran perspectives on the Caring Letters intervention. Investigators will also assess the budget impact of implementing the Caring Letters campaign throughout the entire VA healthcare system.

Principal Investigator: Mark Reger, PhD, is an affiliate investigator with the Center of Innovation for Veteran-Centered and Value Driven Care in Seattle, WA.

Advancing Suicide Prevention for Female Veterans


Between 2005 and 2017, the suicide rate among women Veterans increased 61%, while increasing 43% among male Veterans. Despite the considerable research examining suicide risk factors, barriers to care, and care utilization among Veterans, little research has examined these issues as they relate to women. Investigators expect that results from this study will provide important evidence to support tailoring suicide prevention interventions for women Veterans. Study findings may also help identify high-priority services and barriers to care that will help direct clinical and research priorities for female Veterans at risk for suicidal self-directed violence (SSV). Further, this work has the potential to help the broader population of women Veterans with mental health conditions or other risk factors for SSV.

About the Study

Investigators are developing and testing explanatory models of female and male risk for repeat SSV over 12 months. Over the course of the study period, investigators will also identify similarities and differences in patterns of healthcare utilization, coping strategies, and symptom change over time between female and male Veterans at risk for SSV.

Interviews were conducted with 25 female and 25 male Veterans for whom a non-fatal SSV event was recorded in a suicide behavior report in VA's Corporate Data Warehouse (CDW). Researchers gathered data on the Veterans’ perspectives and experiences with suicidal thoughts and SSV; their recovery needs and experiences with the recovery process; barriers and facilitators to care; and how clinicians and the healthcare system could better identify and address the needs of Veterans like them. Investigators also will survey 570 female Veterans and 430 male Veterans on psychosocial and health-related measures, such as coping efficacy, interpersonal conflict, positive relations with others, trauma, occupational problems, barriers to care, and mental health symptoms. Participants will be followed for 12 months to assess and document all SSV events.

Principal Investigator: Lauren Denneson, PhD, is an investigator with the VA HSR&D Center to Improve Veteran Involvement in Care, in Portland, OR.

Publications Hoffmire CA, Denneson LM. Concerning Trends in Suicide Among Women Veterans Point to Need for More Research on Tailored Interventions. HSR&D FORUM. May 2018.

Denneson LM, Tompkins KJ, McDonald K, et al. Gender Differences in the Development of Suicidal Behavior among United States Military Veterans: A National Qualitative Study. Social Science & Medicine. (E-pub ahead of print.

Study Shows Methods of Suicide Differ Between Stably and Unstably Housed Veterans


Compared to Veterans with stable housing, Veterans who are unstably housed (either currently homeless or at risk for losing housing) are more likely to experience suicidal ideation, suicide attempts, and suicide. Understanding methods of suicide can inform VA’s prevention and intervention efforts, and support suicide prevention programs tailored to unstably housed Veterans. In particular, lethal means safety efforts (i.e., counseling and public health approaches) to suicide prevention should consider unstably housed Veterans at greater risk for using different means of suicide.

About the Study

Investigators examined whether Veterans' methods of suicide varied by housing status by using existing data from 5,849,870 Veterans who were screened for housing instability in VA between October 1, 2012 and September 30, 2016. Investigators determined the date and cause of death over the study period—and examined demographic (e.g., age, gender) and health factors (i.e., depression, alcohol use disorder, drug use disorders) related to risk for suicide. Findings indicated:

  • Across the study period, 169,221 (3%) Veterans were unstably housed. Among the 7,005 Veterans who died by suicide, 4% were unstably housed.
  • Among stably housed Veterans, nearly three of four suicides involved firearms; in contrast, for unstably housed Veterans, less than half of suicides involved firearms.
  • After accounting for demographic and health factors, unstably housed Veterans had an 86% increased risk for suicide from self-poisoning through exposure to drugs and other biological substances, compared to stably housed Veterans.
  • Unstably housed Veterans were more than three times as likely to die by suicide from jumping from a height and more than 2.5 times as likely to die by suicide from unspecified means than stably housed Veterans.

Principal Investigators: John Blosnich, PhD, is an investigator with the Center for Health Equity, Research and Promotion (CHERP), Pittsburgh and Philadelphia, PA, and Ann Elizabeth Montgomery, PhD, is an investigator with the Birmingham VA Medical Center.

Publications: Blosnich JR, Monteith LL, Holliday R, et al. Differences in Methods of Suicide among Veterans Experiencing Housing Instability, 2013-2016. Psychiatry Research. June 2020.

The Impact of COVID-19 and Social Distancing on Mental Health and Suicide Risk in Veterans.


The global pandemic associated with SARS-CoV2, the virus that causes COVID-19, has had a catastrophic impact on every sector of society. The key public health approaches to controlling the spread of the virus—social/physical distancing and mandatory quarantine—have far-reaching implications with regard to mental health. Social distancing is likely to result in loneliness, and a decreased sense of belonging, factors that are connected to suicide risk. Study results are expected to:

  • Clarify the impacts of COVID-19 and social distancing on Veteran well-being, mental health, and suicide risk in order to mobilize an immediate response to the long-lasting effects of the pandemic; and
  • Establish a cohort for a longitudinal study to further understand the long-term impacts of the pandemic on well-being, mental health, and suicide risk in Veterans.

if social distancing causes significant disruptions for Veterans, VA can increase offerings of family and social support interventions such as cognitive behavioral couples’ therapy. Also depending on the results, next phase interventions that target social cognition, psychological inflexibility, and expressed emotion, potentially in combination, could be developed.

About the Study

In this recently funded project, investigators will use VA data to identify Veterans with PTSD, mood disorders, or other psychiatric disorders and will use a social-network survey to assess their experiences during the COVID-19 pandemic. Results will ideally provide insight into changes in Veterans’ social networks over time due to social distancing, and will help identify modifiable treatment factors to inform intervention development.

Principal Investigator: Bryann Debeer, PhD, is an investigator with the Rocky Mountain Mental Illness Research, Education, and Clinical Center.

1. VA Office of Mental Health and Suicide Prevention, 2019 National Veteran Suicide Prevention Annual Report

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