The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: Suicide Prevention in Veterans

Veterans and military personnel represent 20% of suicides in the US. Rates of suicide increased during the wars in Afghanistan and Iraq – and between 2000 and 2010, the suicide rate among Veterans rose to exceed the rate among civilians. Female Veterans are at especially high risk relative to other women. These trends have led to new initiatives within the VA and military to address suicide prevention. In addition to individual-level approaches to suicide prevention, initiatives have been implemented at organizational, health system, and community levels. However, very few studies demonstrating their efficacy and effectiveness have been published. As a result, their influence on suicide prevention remains unclear.

Conducted by investigators with the VA Evidence-Based Synthesis Program (ESP) Center located at the VA Portland Health Care System, this systematic review updates evidence in three key areas:

• Accuracy of methods to identify individuals at increased risk for suicide;
• Efficacy/effectiveness and adverse effects of healthcare service interventions in reducing suicide and other suicidal self-directed violence; and
• Current evidence gaps and relevant ongoing research.

ESP investigators reviewed the literature from January 2008 to September 2015 and identified 28 recently published studies, in addition to 9 studies from previous ESP reviews that met inclusion criteria. Of these 37 studies, 5 included Veterans and 4 included active military personnel.

Findings
Studies of methods to identify individuals at increased risk for suicide and other suicidal self-directed violence evaluated numerous approaches. The majority of methods demonstrated fair or better accuracy in discriminating between patients with and without suicide or suicide attempts. Models using data from electronic healthcare administrative data – including those developed in a large sample of Veterans and active duty military personnel – were fair to good predictors of subsequent suicide. Three risk-assessment methods, two using the large administrative data sets and one using the ReACT Self Harm Rule (uses four elements to identify patients who may be at risk for suicide), were not only relatively accurate but also had low risk of bias.

Studies suggested that some population-level suicide prevention interventions and individual therapies in active military populations reduced suicide attempts and suicide. Suicide rates were lower after interventions in six observational studies, including studies of the Air Force Suicide Prevention Program, a program for an Army Infantry Division deployed to Iraq, and studies of police, college students, and health systems. Promising interventions comprised multiple prevention approaches operating together, and were directed at both soldiers and their surrounding social network (i.e., family or military commanders). Three examples of prevention approaches that were successfully combined include suicide prevention education, resiliency training, and monitoring of suicide events and trends.

Limitations
Overall, the evidence is limited by many single studies with smaller sample sizes. Most of the risk assessment methods have not been repeated or replicated. Many of the intervention studies had methodological challenges, such as unclear comparability of comparison groups and the impracticality of randomization when conducted at a population level.

Future Research
Future research should be directed towards several areas that will help resolve the limitations of the current evidence. Replication and in-depth examination of the most promising risk-assessment methods and population-level interventions in multiple studies and samples is essential. This will help validate promising results of initial studies reported here, translate this work to other settings, and determine how they might be applied in routine healthcare settings and clinical care. The most promising risk assessment methods identified were: a risk algorithm from ARMY STARRs; a prediction model created from VA data that stratified patients according to their risk for suicide within the next year; and the ReACT Self Harm Rule. The most promising interventions identified were: the Air Force Suicide Prevention Program; a suicide prevention program implemented in an Army Infantry Division deployed to Iraq; a brief outpatient cognitive behavioral therapy program in active-duty soldiers; and a dialectical behavior therapy program in women with borderline personality disorder.

In addition, adverse events should be measured and included as an outcome in future research, particularly intervention studies. Finally, further testing of novel and innovative approaches supported by existing developmental work is warranted. Examples include risk-assessment methods measuring objective markers of suicide risk, restricting access to lethal means of killing oneself, and use of technology or peer-support programs to enhance care in high-risk groups.

Reference
Nelson HD, Denneson L, Low A, Bauer BW, O'Neil M, Kansagara D, Teo AR. Systematic Review of Suicide Prevention in Veterans. VA ESP Project #05-225; 2015.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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