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Management Brief No. 191

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Management eBriefs
Issue 191 November 2021

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

Risk and Protective Factors across Socioecological Levels of Risk for Suicide: An Evidence Map

Between 1999 and 2019, suicide rates increased by 33% in the United States. The suicide rate among Veterans is 1.5 times that of the general population, when adjusted for age and sex, thus suicide prevention remains the highest priority for VA. Prior work has examined risk and protective factors among individuals known to be at high suicide risk based on age, sex, and mental health diagnoses. However, little information is available on suicide risk factors in the general population. Understanding such factors may be helpful in developing public health and primary care prevention strategies.

As outlined in the 2020 National Veteran Suicide Prevention Annual Report, Veterans and active military “do not live, work, and serve in isolation….”, recognizing that risk and protective factors are not confined solely to the individual. Therefore, evaluating these factors through the lens of a socioecological framework can provide context for developing suicide prevention policies and practices.

VA’s Evidence Synthesis Program (ESP) Center in Minneapolis, MN, conducted a systematic review of research published since 2011 and prepared an evidence map to identify risk and protective factors associated with suicide or suicide attempts in the general Veteran or active military personnel populations. Investigators searched MEDLINE, Embase, PsycINFO, and Sociological Abstracts from January 2011 to January 2021, identifying 1,351 citations for title and abstract triage; of these, 295 articles were given a full-text review and 63 met study inclusion criteria. Of the 63 studies, 14 were categorized as low risk of bias (ROB), 41 as moderate ROB, and 8 as high ROB. Investigators then interpreted this evidence using the social-ecological model.

Summary of Findings

Among general populations of Veterans or active duty military populations, findings show:

  • A history of prior suicide ideation or attempts, depression/anxiety and substance, alcohol, or tobacco use were consistently predictive of, or associated with, suicide and attempts.
  • PTSD, unlike other common mental disorders studied, was NOT consistently associated with suicide.
  • Marital status was not consistently associated with suicide or attempts, while relationship difficulties were generally consistently found to be risk factors.
  • Community-level, relational-level, and other individual-level factors were reported in only 1 or 2 studies.
  • No studies reported on societal-level risk or protective factors.

Study investigators urge caution in the interpretation and application of their findings. Most results came from moderate risk of bias retrospective cohort studies. Further, the certainty of the overall evidence was limited, due in part to study design, variation across studies in risk factor definitions and categorization, uncertainty in models and variables used to assess the independent effect of reported factors, and lack of predictor reporting.

Future Research

The currently available evidence is perhaps most notable for its limitations and gaps, emphasizing the need for future research on risk and protective factors for suicide across social-ecological domains. For example, additional exploration of factors such as firearm status, marital status, and various forms of interpersonal violence is warranted. The creation of large cohorts to prospectively collect data specifically targeted to potential social-ecologic factors, both known and unknown, in general populations associated with increased risk would be useful. There is also little research on the potential combination of factors in predicting suicide or suicide attempts. More refined analytic methods are needed to adjust for known and potential confounders, and to better understand whether results are due to exploratory analyses, chance, or limited statistical power.

A Cyberseminar titled “Risk and Protective Factors across Socioecological Levels of Risk for Suicide: An Evidence Map” will be held on December 1, 2021 from 11:00am – 12:00pm ET. Register here.

Ullman K, Landsteiner A, Linskens E, MacDonald R, McKenzie L, Murdoch M, Sayer N, Stroebel B, Sultan S, Venables N, Wilt TJ. Risk and protective factors across socioecological levels of risk for suicide: an evidence map. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2021.

To view the full report, go to

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence 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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