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Objective: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. Methods: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. Results: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. Conclusions: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care. [ABSTRACT FROM AUTHOR]

Introduction: The Virtual Hope Box (VHB) mobile application is an adapted version of the conventional hope box intervention that is used in several evidence‐based treatments for suicide behaviors. The VHB is an award‐winning app developed by a collaboration between the Departments of Defense and Veterans Affairs. Multiple studies have assessed the utility and effectiveness of the VHB for use in suicide prevention, but no reviews of the literature have been conducted. Methods: Authors performed a review of the literature using PsycINFO, EBSCOhost, and PubMed. 15 articles were ultimately included. Results: Results were categorized into three areas: (1) efficacy and effectiveness, (2) feasibility, awareness, and usage in high‐risk populations, and (3) implementation approaches to increase use among patients and providers. Existing evidence for the VHB supports its feasibility and acceptability, especially among military and veteran populations. Only one study investigated effectiveness in a randomized control trial. Although the VHB developers have disseminated the app nationally, low adoption rates among veteran patients and VA providers remain. Studies found that educational implementation strategies can improve utilization rates. Conclusions: Future research should examine suicide behaviors as outcomes, approaches to incorporating the VHB into treatment, and a range of populations. [ABSTRACT FROM AUTHOR]

In the evidence-based suicide prevention intervention, Caring Letters, healthcare providers send brief, caring messages to patients following psychiatric inpatient care, a time of elevated suicide risk. However, recent studies with military populations have found mixed results. An adaptation of Caring Letters employed a peer framework in which veterans from the community wrote brief caring messages to veterans discharging from psychiatric inpatient treatment after a suicidal crisis. The present study utilized content analysis to assess 90 caring messages generated by 15 peer veterans recruited from veteran service organizations (e.g., American Legion). Three themes emerged: (1) Shared Military Service, (2) Care, and (3) Overcoming Adversity. Peer-generated content varied in how the coded themes were expressed in the messages. These veteran-to-veteran caring messages may bolster belongingness, social support, and destigmatize mental health struggles, and have the potential to augment existing Caring Letters effects and interventions. Veterans commonly wrote about shared military services, care, and adversities. Supportive messages from peers may be tied to social support. Our analyses support possible benefits for veterans receiving caring messages. [ABSTRACT FROM AUTHOR]

Suicide is a leading cause of death in the United States. This has prompted the U.S. surgeon general to issue a report describing actionable items to reduce suicide rates, including a recommendation to increase the use of the caring letters intervention. This intervention involves mailing brief, nondemanding messages of care. As part of the Department of Veterans Affairs' (VA's) efforts to reduce suicide rates among veterans, a caring letters project was developed for veterans who contact the Veterans Crisis Line (VCL). This article describes the results of qualitative interviews conducted to better understand the experiences of veterans who received caring letters. Beginning in 2020, all identifiable veterans who used Veterans Health Administration services and contacted the VCL received nine letters over 1 year, along with a list of mental health resources. Semistructured interviews (N=23) were conducted, and content analysis was used to identify veterans' perspectives and suggestions for improving the intervention. Sixteen men and seven women participated (mean age=53 years). Feedback varied, with most participants reporting that receiving caring letters had a positive impact and others noting aspects that could be improved to enhance the intervention's caring intent. Some also reported that the letters helped them engage with community resources and made them more likely to seek VA care. The caring letters intervention, received after contact with the VCL, was well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future evaluation examining veteran outcomes. [ABSTRACT FROM AUTHOR]

The U.S. Department of Veterans Affairs (VA) and Department of Defense clinical practice guideline on the treatment of veterans at risk for suicide recommends considering caring contacts interventions after a psychiatric hospitalization for suicidal ideation or suicide attempt. This quality improvement project examined the implementation of the recommendation at a large VA health care system. The project enrolled 29% of hospitalized veterans (N=135 of 462). Enrollment barriers included lack of staff availability and veteran ineligibility due to homelessness or housing instability. Opportunities to improve the reach of the intervention in future quality improvement processes are discussed, especially because acceptability of the intervention was high among veterans. [ABSTRACT FROM AUTHOR]

The Department of Defense Suicide Event Report Program collects extensive information on suicides and suicide attempts from the U.S. Air Force, Army, Marine Corps, and Navy. Data are compiled on demographics, suicide event details, behavioral health treatment history, military history, and information about other potential risk factors such as psychosocial stressors that were present at the time of the event. The ultimate goal of this standardized suicide surveillance program is to assist suicide prevention in the U.S. military. Descriptive data are presented on 816 suicides and 1,514 suicide attempts reported through the program between 2008 and 2010. (Contains 6 tables.)

Suicide risk based on occupational cohorts within the U.S. military was investigated. Rates of suicide based on military occupational categories were computed for the Department of Defense (DoD) active component population between 2001 and 2010. The combined infantry, gun crews, and seamanship specialist group was at increased risk of suicide compared to the overall military population even when adjusted for gender, age, and deployment history. The results provide useful information that can help inform the DoD's suicide prevention mission. Data limitations and recommended areas for future research are discussed. (Contains 2 tables.)

The involvement of anger in the psychological adjustment of current war veterans, particularly in conjunction with combat-related posttraumatic stress disorder (PTSD), warrants greater research focus than it has received. The present study concerns a brief anger measure, Dimensions of Anger Reactions (DAR), intended for use in large sample studies and as a screening tool. The concurrent validity, discriminant validity, and incremental validity of the instrument were examined in conjunction with behavioral health data for 3,528 treatment-seeking soldiers who had been in combat in Iraq and Afghanistan. Criterion indices included multiple self-rated measures of psychological distress (including PTSD, depression, and anxiety), functional difficulties (relationships, daily activities, work problems, and substance use), and violence risk. Concurrent validity was established by strong correlations with single anger items on 4 other scales, and discriminant validity was found against anxiety and depression measures. Pertinent to the construct of anger, the DAR was significantly associated with psychosocial functional difficulties and with several indices of harm to self and to others. Hierarchical regression performed on a self/others harm index found incremental validity for the DAR, controlling for age, education, military component, officer rank, combat exposure, PTSD, and depression. The ability to efficiently assess anger in at-risk military populations can provide an indicator of many undesirable behavioral health outcomes. (Contains 7 tables and 4 footnotes.)

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model. [ABSTRACT FROM AUTHOR]

Internet-and computer-based cognitive-behavioral treatments have been introduced as novel approaches to deliver standard, quality treatment that may reduce barriers to care. The purpose of this review is to quantitatively summarize the literature examining the treatment effects of Internet- or computer-based treatment (ICT) on anxiety. Nineteen randomized controlled ICT trials were identified and subjected to fixed and random effects meta-analytic techniques. Weighted mean effect sizes (Cohen's d) showed that ICT was superior to waitlist and placebo assignment across outcome measures (ds = .49-1.14). The effects of ICT also were equal to therapist-delivered treatment across anxiety disorders. However, conclusions were limited by small sample sizes, the rare use of placebo controls, and other methodological problems. In addition, the number of available studies limited the opportunity to conduct analyses by diagnostic group; there was preliminary support for the use of ICT for panic disorder and phobia. Large, well-designed, placebo-controlled trials are needed to confirm and extend the results of this meta-analysis. Keywords: Internet; computer; cognitive-behavioral therapy; metaanalysis; anxiety

Introduction: The US Department of Veterans Affairs (VA) is a national leader in the implementation of clinical video telehealth (CVT) services. Despite the growth of mental-health services offered via CVT, it is unclear to what extent these services are offered and accessed by veterans with previous suicidal behaviour.Methods: The current quality improvement project examined this question within a local VA health-care system using data from suicide behaviour reports (SBRs), the Veteran Health Administration's official reporting and surveillance system. The frequency of SBRs was compared during two different time points among veterans who received individual mental-health appointments in person only or via CVT during the 2017 calendar year. Among veterans with a SBR, time in days elapsed from their first mental-health appointment to a SBR was examined as a function of treatment modality.Results: Results indicated veterans who received in-person treatment only were more likely to present with a SBR six months prior to their first mental-health appointment compared to those who received CVT during the observation period. There were no differences in SBRs during the 12 months after the first appointment or the time from the first appointment to the SBR as a function of treatment modality used.Discussion: Although veterans who received in-person mental-health services were more likely to have had a SBR six months prior to treatment, suicide risk throughout the observation period did not differ between groups. Clinical implications that arise from these findings are described in the discussion. [ABSTRACT FROM AUTHOR]

The Veterans Crisis Line (VCL) is a national resource offering Veterans 24/7 access to crisis respon- ders and follow-up by a licensed mental health clinician at a Veterans Affairs medical center. This quality improvement project aimed to improve local suicide prevention efforts at the VA Puget Sound Health Care System by characterizing 344 VCL calls and outcomes. Data was extracted from documentation by national VCL responders and local Suicide Prevention Team members. Overall, most callers were assessed at low-to-moderate risk. VCL responders were more likely to assess callers reporting suicidal ideation (SI) as high-risk, but less likely to assess those reporting financial issues as high-risk. VCL calls about SI, about physical health, or that occurred on weekends were more likely to end with immediate evaluation (i.e., emergency room, evaluated by first-responders) compared to their respective comparison groups. VCL calls assessed as high-risk were more likely to report SI during local follow-up contact, whereas VCL calls ending in immediate evaluation (i.e., emergency room, evaluated by first-responders) were less likely to report SI during follow-up with the local VA clinician; 17% of VCL calls without SI reported SI at follow-up. Training of local Suicide Prevention Team members should include that SI can change rapidly and requires assessment regardless of SI during the VCL call. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VHA) implemented REACH VET, which analyzes health records to identify veterans at statistically elevated risk for suicide and other adverse outcomes compared to other veterans in VHA. This project evaluated REACH VET program implementation at a large VA health care system by examining program fidelity and treatment engagement, receipt of suicide prevention interventions, and suicide‐related behaviors in the 6 months following identification. Methods: Over a 12‐month period, 218 unique cases were identified by REACH VET within a local VA system. Data were extracted from the VA's electronic medical records. Results: Protocol adherence for required clinical and administrative steps was 94% and above. After identification, 88% received outpatient mental health treatment, 21% had a psychiatric hospitalization, and 83% engaged in Safety Planning around the time of identification or in the following six months. Twenty‐six percent of cases were identified by another existing method for identifying high‐risk veterans. Five percent had a medically documented suicide attempt, and none were known to die by suicide in the following 6 months. Conclusions: Local evaluation suggested high protocol fidelity and high engagement in mental health and suicide prevention services following identification among veterans who remained at elevated risk in the 6 months that followed. [ABSTRACT FROM AUTHOR]

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs. [ABSTRACT FROM AUTHOR]

SUICIDE PREVALENCE IN LBD, PD, AND DEMENTIA Suicide The prevalence of SI, suicide attempts, and suicide in LBD are not well researched. Implications for LBD Younger individuals with LBD and those of white race may be at a higher risk of suicide based on studies in PD and dementia (Table 1). Research suggests, though, that most individuals with dementia do not access palliative care or access it only in the last weeks of life.80 In a recent study of end of life in LBD, survey respondents said that hospice was used by 78% of individuals with LBD (higher than prior dementia studies), but 40% had hospice initiated less than a month before death.18 Additionally, some caregivers of individuals who died with LBD reported that they were never told that LBD could be terminal. [Extracted from the article]

Objective: There is significant debate about the feasibility of using predictive models for suicide prevention. Although statistical considerations have received careful attention, patient perspectives have not been examined. This study collected feedback from high-risk veterans about the U.S. Department of Veterans Affairs (VA) prevention program called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET).Methods: Anonymous questionnaires were obtained from veterans during their stay at a psychiatric inpatient unit (N=102). The questionnaire included three vignettes (the standard VA script, a more statistical vignette, and a more collaborative vignette) that described a conversation a clinician might initiate to introduce REACH VET. Patients rated each vignette on several factors, selected their favorite vignette, and provided qualitative feedback, including recommendations for clinicians.Results: All three vignettes were rated as neutral to very caring by more than 80% of respondents (at least 69% of respondents rated all vignettes as somewhat caring to very caring). Similar positive feedback was obtained for several ratings (e.g., helpful vs. unhelpful, informative vs. uninformative, encouraging vs. discouraging). There were few differences in the ratings of the three vignettes, and each of the three scripts was preferred as the "favorite" by at least 28% of the sample. Few patients endorsed concerns that the discussion would increase their hopelessness, and privacy concerns were rare. Most of the advice for clinicians emphasized the importance of a patient-centered approach.Conclusions: The results provide preliminary support for the acceptability of predictive models to identify patients at risk for suicide, but more stakeholder research is needed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The Caring Contacts suicide prevention intervention has been promoted by the Joint Commission, given its effectiveness, high reach, and cost effectiveness. Despite its increased application, no study has examined whether patient characteristics influence perceptions of the intervention, which may inform implementation efforts and ultimately impact effectiveness. One hundred fifty-four veterans were recruited from a Veterans Affairs psychiatric inpatient unit. Participants completed a survey to provide feedback on preferences, including the message correspondent, format (e.g., postcard, email), the importance of handwriting (vs. typed), visual presentation, and schedule for mailings. Results demonstrated that Caring Contacts preferences did not differ by most variables, including military rank, combat deployment history, or most personal technology use characteristics. Some demographic differences were identified, especially by age. More older veterans preferred messages to be sent in a physical letter compared to younger veterans, but if messages were sent via postal mail, younger veterans had a stronger preference for messages to be handwritten and sent using real stamps and colorful envelopes. Overall, findings suggest that few Caring Contacts adaptations are needed based on patient characteristics. Programs targeting older cohorts should consider postal mail formats for Caring Contacts. [ABSTRACT FROM AUTHOR]

Objective: Veterans die by suicide at a higher rate than the U.S. population, and veterans more frequently use a firearm as the suicide method. Consequently, firearm accessibility and storage represent important prevention considerations. This project aimed to explore the implementation of suicide prevention efforts among veterans who went on to die by suicide, with and without the use of a firearm, and to identify factors that differentiated veteran suicide decedents to help inform suicide prevention efforts.Methods: Data from the Veteran Health Administration Behavior Health Autopsy Program was analyzed for 97 veteran suicide decedents.Results: Results demonstrated that veterans who used a firearm for suicide were less likely to have engaged in suicide prevention efforts overall and were less likely to have received lethal means safety counseling / safety planning. Veterans who died by firearm had lower levels of notable risk factors (e.g., prior suicide attempt, no-shows for appointments), however were more likely to have a documented unsecured firearm in their home.Conclusion: These findings support the benefit of broadening the reach of suicide prevention efforts, especially for high-risk veterans with access to firearms. [ABSTRACT FROM AUTHOR]