Which veterans have the highest risk of dying by suicide? New study sheds light

In the ongoing effort to reduce the number of veterans who die by suicide, a new study identifies key factors that predict whether veterans who received a Comprehensive Suicide Risk Evaluation, the standardized suicide risk assessment implemented nationally in the Veterans Health Administration, will go on to die by their own hands.

The findings could help Veterans Affairs clinicians and others work to prevent more suicide deaths among veterans in this high-risk category. 

The study focused on veterans who received a CSRE assessment from a VA clinician. The CSRE program launched nationally six years ago, and the new study looks at suicide deaths among veterans who received an assessment during its first year.

Even after going through the CSRE process, the new study finds that veterans who were actively experiencing suicidal thoughts, had made suicide plans, had access to firearms, or had a history of mental health inpatient stays were most likely to die by suicide, compared with others who had been through a CSRE but didn’t have these risk factors. 

The study looked at suicide deaths both in the first 30 days and the first year after a CSRE. 

In all, there were 791 suicides following the 269,374 CSREs that were completed for 153,736 Veterans Health Administration patients between November 2019 and December 2020, the study finds. Of those, 144 suicides occurred within 30 days after a CSRE; the rest were within a year of the CSRE visit. 

While most of those who died by suicide after a CSRE had been classed as having an especially high risk of near-term or long-term suicide based on their answers on the CSRE scale, there were also suicide deaths among those who fell into the lower-risk category on their CSRE. 

The study, published in JAMA Network Open by a team from the University of Michigan Medical School’s Department of Psychiatry, the VA Center for Clinical Management Research, and the VA Ann Arbor Healthcare System, was led by Kevin Saulnier, Ph.D., a psychologist who has performed CSREs as part of his practice at VA Ann Arbor’s mental health clinic. 

“Suicide prediction has long been a challenge for the field, so this finding that some of the risk factors that are routinely assessed in the Veterans Health Administration predicted future risk of suicide is important,” says Saulnier. “While this study did not look at what treatments and supports patients received after their CSRE, it can immediately inform clinicians as they use their judgement to work with patients.” 

Saulnier and colleagues also recently published another paper in JAMA Network Open showing that suicide mortality was lower among veterans newly diagnosed with post-traumatic stress disorder who received the evidence-based treatment know as cognitive processing therapy or prolonged exposure (CPT/PE).

More about CSREs

CSRE sessions, which can take about a half hour, are designed to evaluate a veteran’s current risk factors and protective factors for suicide using a standardized checklist.

Part of the appointment can be the development of a safety plan that maps out who the veteran can turn to when they feel suicidal, including the Veterans Crisis Line that can be reached by phone at 988, by text at 838255 and by online chat at https://www.veteranscrisisline.net/. 

Depending on the clinician’s judgment and the patient’s preferences, a CSRE can also lead to referrals to specific mental health care, the provision of free gun locks for any firearms the veteran possesses, and other steps. 

In some states, including Michigan, “red flag” laws allow clinicians, family members and law enforcement to seek a court order to remove firearms from the home of a person they believe to be a danger to themselves or others. The U-M Institute for Firearm Injury Prevention offers a free toolkit to help individuals understand this option, called an Extreme Risk Protection Order.

Using research to improve care

The new study could help clinicians prioritize firearm-related steps for CSRE patients, as well as escalating patients with current suicide-related thoughts or plans to higher levels of care including inpatient psychiatric care if needed. 

Saulnier notes that predictive models for suicide have already become part of VA care management decisions, and that the new findings could help refine those models. He and colleagues are also planning to study what treatments veterans received after having a CSRE, and also non-fatal suicide attempts. 

The study only includes veterans receiving care from the VA, where brief screening for suicide risk is universal. CSREs have become standard care for those whose initial screen shows that they have been having suicidal thoughts or thinking about how they might attempt suicide. 

Veterans cared for in non-VA settings may not get screened for suicide risk unless they’re seeking care for a behavioral health issue, though more hospitals and health systems are now implementing universal screening and follow-up evaluations for those who screen positive. 

More about the study

In addition to the factors that predicted suicide deaths by 30 or 365 days after a CSRE, Saulnier and colleagues also found some factors were actually linked to a protective effect, or reduced risk. 

More research on this is needed, he said – including research on those who completed CSREs and were considered very high risk for immediate or later suicide but did not die by suicide during the follow-up period.

The team also found that some factors that have been seen in other research as protective against suicide risk were not associated with lower risk of suicide death, such as connection to others or a sense of hope. This may be due to the very high risk of suicide that veterans who receive CSREs already face. 

In an accompanying commentary, Rebecca Rossom, M.D., M.S. of the HealthPartners Institute wrote, “As the largest integrated health system in the US, true universal suicide risk screening followed by safety planning in the Veterans Health Administration could provide powerful evidence regarding the effectiveness of these approaches to suicide prevention. These findings are critical as the US continues to grapple with the public health epidemic of suicide.”

In addition to Saulnier the study’s authors are Courtney L. Bagge, Ph.D.; Dara Ganoczy, M.P.H.; Nazanin H. Bahraini, Ph.D.; Jennifer Jagusch, M.S.W.; Avinash Hosanagar, M.D.; Mark A. Ilgen, Ph.D.; and Paul N. Pfeiffer, M.D. Saulnier, Bagge, Pfeiffer and Ilgen are members of the U-M Institute for Healthcare Policy and Innovation and the VA CCMR.

This research is supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Ann Arbor VA Healthcare System, and the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC).

More information about veteran suicide risk, prevention, options for reducing access to lethal means such as firearms, and crisis support is available at https://www.mentalhealth.va.gov/suicide_prevention/index.asp 

If you or someone you know may be considering suicide, or having a mental health or addiction-related crisis, the 988 Lifeline is available for free to anyone, at all times, in both English and Spanish. Call 988 from any phone, text 988 from a mobile device, or visit https://988lifeline.org/ for live webchat, information on available help, and live help via videophone for people who are Deaf or hard of hearing.  Or contact the Crisis Text Line by texting TALK to 741741.