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This study reports on gender differences in psychosocial symptoms and suicidal thoughts and behaviors from the first longitudinal, national survey of veterans with a recent nonfatal suicide attempt to inform women-tailored suicide prevention. We recruited all female veterans with a documented nonfatal suicide attempt between October 2018 and September 2019 and a stratified matched sample of males. Surveys were administered at baseline, month 6, and month 12; 968 veterans completed the baseline survey with valid gender data. Surveys assessed psychosocial constructs, suicidal ideation severity, and suicidal behavior. Administrative datasets provided healthcare and suicide attempt data during the one year follow up. Women retained higher social rejection and institutional betrayal, and lower self-compassion and autonomy than men over follow up. Higher overall self-compassion was associated with lower baseline suicide ideation for both women and men; however, this association was stronger for women (Δ = −0.19; 95 % CI = -0.31, −0.07; d = −0.15). Individuals with higher overall psychological distress had greater odds of a subsequent suicide attempt (AOR = 2.20, 95 % CI = 1.56, 3.11). Social rejection had the strongest association with worsening psychological distress, both within individuals (b = 0.18; 95 % CI = 0.14, 0.23; d = 0.23) and between individuals (b = 0.07; 95 % CI = 0.04, 0.10; d = 0.09). Results may not generalize beyond a VHA-utilizing veteran population. Findings from this study inform potential therapeutic targets and topics for future research on tailoring suicide prevention for women veterans. While all veterans may need support reducing distress, women may need additional support in multiple other areas. • Tailored suicide prevention strategies for women veterans are needed. • Psychological distress is a core contributor to suicide risk among veterans. • Women veterans carry higher psychosocial risk and lower resilience than men. • Chronic illness approaches are warranted for veterans with recent suicide attempts. [ABSTRACT FROM AUTHOR]

Background : In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings. Objective: The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program. Design: Mixed methods; survey and qualitative interviews. Participants: Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews. Main Measures: The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID. Key Results: Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered. Conclusions: Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts. [ABSTRACT FROM AUTHOR]

Developing a public health approach to suicide prevention among United States (US) military veterans requires additional data and guidance on where, when, for whom, and what prevention resources should be deployed. This study examines veteran suicide mortality across one US state (Oregon) to identify county-level "hotspots" for veteran suicide, identify community characteristics associated with increased suicide among veterans, and examine excess spatial risk after accounting for space, time, and community characteristics. We linked Oregon mortality data with VA databases to identify veterans who had resided in Oregon and died by suicide between January 1, 2009 and December 31, 2018 (n = 1727). Community characteristic data were gathered at the county level from publicly available datasets on social determinants of health known to be associated with poor health outcomes, including suicide risk. We estimated spatial generalized linear mixed models for the full 10-year period and for each 5-year period using integrated nested Laplace approximation with county as the higher hierarchy. Smoothed standardized mortality ratios were used to identify counties with higher risk of veteran suicide. We found a small clustering of counties in the southwestern corner of Oregon that held the highest risk for veteran suicide across the ten years studied. In multivariable models, higher prevalence of unmarried persons was the only community measure significantly associated with increased veteran suicide risk. However, social contextual factors as a group, along with geographic space, explained most risk for suicide among veterans at the population level. • Veterans are at increased risk for suicide relative to nonveterans. • Hotspots for veteran suicide in Oregon cluster in rural, southwestern counties. • Social determinants of health and space explain almost all variation in suicide. [ABSTRACT FROM AUTHOR]

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow-up (n = 168; 57%). Fifty-three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine primary care clinician actions following positive suicide risk assessments administered to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. Methods: We identified OEF/OIF veterans with positive templated suicide risk assessments administered in primary care settings of three Veterans Affairs (VA) Medical Centers. National VA datasets and manual record review were used to identify and code clinician discussions and actions following positive assessments. Bivariate analyses were used to examine relationships between patient characteristics and discussions of firearms access and alcohol/drug use. Results: Primary care clinicians documented awareness of suicide risk assessment results for 157 of 199 (79%) patients with positive assessments. Most patients were assessed for mental health conditions and referred for mental health follow-up. Clinicians documented discussions about firearms access for only 15% of patients. Among patients whose clinicians assessed for substance abuse, 34% received recommendations to reduce alcohol or drug use. Depression diagnoses and suicidal ideation/behavior severity were significantly associated with firearms access discussions, while patient sex, military service branch, and substance abuse diagnoses were significantly associated with recommendations to reduce substance use. Conclusion: Greater efforts are needed to understand barriers to clinicians' assessing, documenting and counseling once suicidal ideation is detected, and to develop training programs and systems changes to address these barriers. [Copyright &y& Elsevier]

Research on warning signs, defined as acute risk factors for suicide or suicide attempt, has been slow due to the difficulty of examining the hours and minutes preceding suicidal behavior. This study sought to identify new warning signs and to re-examine warning signs that have been proposed. Narrative stories of adult patients with substance use problems hospitalized following a suicide attempt were transcribed. The narrative segments describing the 24-h period prior to suicide attempt were examined with directed qualitative content analysis using codes based on prior literature and new codes developed inductively. The sample (N = 35) was mean age = 40, 51% female, and 49% White non-Hispanic. Analysis of the transcripts of the 24-h periods (M word count = 637) yielded a broad range of cognitive (e.g., cognitive disturbance such as rumination), behavioral (e.g., alcohol use), emotional (e.g., dramatic mood changes), and social (e.g., social withdrawal) warning signs, along with a small number of cognitions and behaviors that appeared to mark a dangerous shift to acute preparation and intent for attempt, for example 'self-persuasion to attempt suicide.' We posit that a broad range of cognitive, behavioral, emotional, and social warning signs increase acute risk for suicidal behavior by creating the conditions for a shift to acute preparation and intent, a highly potent category of warning signs. [ABSTRACT FROM AUTHOR]

To better understand processes of mental health crisis line utilization by examining associations between reasons for contacting a crisis line with the initiation of emergency dispatches (i.e., activation of 911 or local emergency services) in a national sample. Contacts (i.e., calls, texts, email, and chats) to the Veterans Crisis Line (VCL) across 2017–2020 were used to examine associations among stated reasons for the contact and the use of an emergency dispatch. Hierarchical logistic regression models were used to determine the odds of an emergency dispatch by reason for the contact. Suicidal thoughts/crisis were present in 61.5% of contacts that ended in emergency dispatches and were associated with the largest adjusted odds of a dispatch, (Adjusted Odds Ratio [AOR] [95% CI] = 9.34 [9.21, 9.48]), followed by homicidal thoughts/crisis (AOR [95% CI] = 3.84 [3.73, 3.95]), and third-party concerns (AOR [95% CI] = 2.42 [2.37, 2.47]). Substance use/ addiction (AOR [95% CI] = 2.14 [2.10, 2.18]), abuse and violence (AOR [95% CI] = 1.89 [1.82, 1.96]), and physical health (AOR [95% CI] = 1.87 [1.84, 1.91]) were also associated with increased odds of a dispatch. Emergency dispatches are primarily used in response to imminent suicide risk but are also used in other potentially violent or lethal circumstances such as homicides, violence or abuse, and other crises. These findings highlight the role that crisis lines play in emergency service delivery, and the need to better understand how they are utilized under real world circumstances. • Veterans Crisis Line (VCL) contacts that were most likely to result in an emergency dispatch were those with suicidal thoughts/crisis • Homicidal thoughts/crisis, third party concerns, substance use/addiction, abuse and violence, and physical health were also associated with emergency dispatches • Emergency dispatches are primarily used for suicidal crises, but are also used for other contacts with potential for injury or death [ABSTRACT FROM AUTHOR]

Objective: To inform measure selection when examining gender differences in suicide risk, this paper evaluates measure performance for a set of gender‐relevant constructs and examines gender differences in mean scores. Methods: A national sample of veterans (n = 968) who had recently attempted suicide (past 6 months) completed measures assessing life experience‐, psychosocial‐, and health‐related constructs. A multigroup latent variable model was used to assess similarity of measurement properties between women and men. Results: Metric and scalar invariance indicated that the latent variables functioned similarly between women and men. Women had higher scores on negative coping, institutional betrayal, and social rejection; men had higher scores on self‐compassion, autonomy, and suicide ideation. Conclusions: Measurement properties and gender differences in mean values support the use of these measures for research on gender differences. Findings also suggest further investigation of social rejection, institutional betrayal, and negative coping among women veterans at risk for suicide. [ABSTRACT FROM AUTHOR]

A 'Hope Box' is a therapeutic tool employed by clinicians with patients who are having difficulty coping with negative thoughts and stress, including patients who may be at risk of suicide or nonsuicidal self-harm. We conducted a proof-of-concept test of a 'Virtual' Hope Box ( VHB)-a smartphone app that delivers patient-tailored coping tools. Compared with a conventional hope box integrated into VA behavioral health treatment, high-risk patients and their clinicians used the VHB more regularly and found the VHB beneficial, useful, easy to set up, and said they were likely to use the VHB in the future and recommend the VHB to peers. [ABSTRACT FROM AUTHOR]