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Publication Briefs

Healthcare Processes Linked to Suicide Risk Following Discharge from VA Residential Substance Abuse Treatment

Studies have found that individuals with substance use disorder (SUD) are at an elevated risk for suicide, and one study found that among 4.8 million patients treated in the VA healthcare system, male Veterans with a current diagnosis of any SUD were at nearly two times greater risk for suicide. Further, some studies suggest that the period following discharge from a residential drug treatment program may represent a period of heightened suicide risk similar to psychiatric hospitalization. Therefore, this retrospective study examined 39 root-cause analysis (RCA) reports of suicide in Veterans occurring within three months of discharge from a residential drug treatment program that were reported to any one of 140 VA medical centers between 2001 and 2017. RCA is a well-known and robust approach to elucidating the contribution of systems and organizational processes to adverse events such as suicide after hospital discharge.


  • Most suicides occurred in close proximity to discharge from a treatment program, with 56% (N=22) occurring within seven days of discharge and 36% (N=14) occurring within 48 hours of discharge.
    • The most common method of suicide was overdose (33%), followed by hanging (28%).
  • Categories of root causes ranged from problems with suicide risk assessment to non-engagement in treatment. The largest number of root causes of suicide pertained to problems with risk assessment, breakdowns in communication, and problems with the discharge process. This was followed by problems with treatment of mental health disorders and non-engagement with treatment during the residential stay – and after discharge.
    • Lack of patient engagement was related to willingness to participate in treatments that might mitigate suicide risk – and to involve family or loved ones in discharge planning.


  • Efforts to prevent suicide after discharge from a treatment program should focus on addressing suicide risk factors during admission and helping patients engage more fully in SUD treatment.


  • This study is likely not representative of all suicides occurring soon after discharge from a VA residential drug treatment program. While facilities are required to conduct an RCA on a suicide occurring within seven days of inpatient mental health discharge, this requirement does not apply to residential programs.
  • Investigators were unable to adjust findings for potential baseline confounding because reports do not reliably provide individual characteristics and cannot be linked to medical records.

Dr. Shiner is supported by an HSR&D Career Development Award (CDA 11-263) and is part of the VA Medical Center and Patient Safety Center of Inquiry for Prevention of Suicide in White River Junction, VT.

PubMed Logo Riblet N, Kenneally L, Shiner B, and Watts B. Healthcare Processes Contributing to Suicide Risk in Veterans During and After Residential Substance Abuse Treatment. Journal of Dual Diagnosis. June 28, 2019; Epub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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