INTRODUCTION:The year following military service separation is a high-risk period for suicide among reintegrating veterans, those transitioning from military service member to veteran. This randomized controlled pilot trial examined the feasibility and acceptability of health coaching, a non-clinical health behavior change modality, among reintegrating veterans and evaluated change in measures of identity coherence, reintegration functioning, and suicidal ideation. METHODS:Reintegrating veterans (n = 95) were randomized to receive either enhanced current reintegration services (eCRS) only or health coaching plus eCRS. Participants completed assessments at baseline, month 2, month 4, and month 9. Health coaching participants completed up to 12 health coaching sessions within 4 months of randomization. RESULTS:Feasibility was strong, indicated by a 23% enrollment rate, participant session completion (mean = 8), and intervention fidelity ratings ≥ 88%. Participants reported high acceptability; 95% indicated that health coaching met their approval. Significant treatment effects were observed for reintegrating functioning, with moderate-to-large effect sizes (d = 0.58 among the health coaching group and d = -0.11 among eCRS). Promising effects were observed for identity coherence measures and suicidal ideation prevalence. CONCLUSIONS:Additional research is warranted to test the efficacy of health coaching on these outcomes in a fully powered randomized controlled trial and to evaluate implementation procedures. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT05199467.

INTRODUCTION:Veterans who do not utilize Veterans Health Administration care are considered a high public health priority because they are disproportionately represented among veteran suicide deaths. This study focused on identifying clinical and social characteristics associated with Veterans Health Administration outpatient mental healthcare utilization among veterans after a positive suicide risk screening (e.g., reporting suicidal intent or plan within past 30 days). METHODS:This study conducted a retrospective, observational cohort study evaluating clinical and social predictors of Veterans Health Administration outpatient mental healthcare utilization 6 and 12 months after suicide risk screening within a primary care or mental health setting. Data were extracted from Veterans Health Administration's Corporate Data Warehouse, a compilation of data from electronic health records and other healthcare data sources. The sample included all veterans with a positive suicide risk screening in Veterans Health Administration Fiscal Year 2020 (October 1, 2019-September 30, 2020). Data were analyzed utilizing mixed-effects, multivariable logistic regression models controlling for age, gender, race, and Latine ethnicity. The study team conducted chart reviews in a random subsample of the analytic sample to identify potential care processes contributing to mental healthcare utilization. RESULTS:Across settings, veterans who did not utilize Veterans Health Administration outpatient mental health care after a positive suicide risk screening had fewer mental/medical comorbidities, fewer social determinants of health challenges (e.g., unemployment), and less past Veterans Health Administration mental healthcare utilization. Chart reviews showed absence of documented mental healthcare referrals as a common barrier to postscreening mental health outpatient care utilization. CONCLUSIONS:Veterans and providers may benefit from education and strategies for addressing barriers to mental healthcare utilization after a positive suicide risk screening with a particular focus on understanding referral processes. Future research should further explore modifiable processes to increase Veterans Health Administration mental health outpatient care utilization after a positive suicide risk screening.

The current authors respect Boffa and Houtsma's (see record 2027-56797-001) interest in their article (see record 2024-23207-001) and Boffa and Houtsma's passion for the topic of patient high-risk flags for suicide. They appreciate the opportunity to clarify their study's aims and conclusions, which appear to have been misinterpreted by Boffa and Houtsma. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Importance:Financial strain is associated with suicide risk; however, no research has examined financial stressors in the year preceding suicide using national credit data. Objective:To assess financial stressors in the 12 months preceding suicide in a national sample of veterans by linking financial, mortality, and health care records. Design, Setting, and Participants:This case-control study of 5000 veterans who died by suicide (January 1, 2015 to December 31, 2017) used mortality data from the US Department of Veterans Affairs (VA) and the US Department of Defense. Cases were matched to 12 500 living controls on age, sex, VA health care use, and suicide index date. Analyses were conducted in December 2025. Exposures:Financial stressors in the prior 12 months were identified in TransUnion credit records provided by FinThrive. Main Outcomes and Measures:The primary outcome was death by suicide. Differences between cases and controls were analyzed using multivariable conditional logistic regression, adjusting for demographics and, among VA users, marital status and diagnoses of depression, posttraumatic stress disorder, and substance use disorder. Results:Among 17 439 veterans included in this study, the mean (SD) age was 52.9 (15.7) years, and 94.6% were male. Suicide was associated with having (vs not having) delinquent mortgage payments (odds ratio [OR], 1.4; 95% CI, 1.2-1.7), repossessions (OR, 1.9; 95% CI, 1.3-2.7), and credit card payments 30 or more days past due (OR, 1.7; 95% CI, 1.6-1.9). Lower credit score categories were associated with increasing odds of suicide. Veterans with 3 or more financial stressors had higher odds of suicide (OR, 2.4; 95% CI, 1.9-3.0) compared with those who had none. Among individuals with available data, credit score declines of 51 to 100 points (OR, 1.3; 95% CI, 1.1-1.5) and greater than 100 points (OR, 2.8; 95% CI, 2.3-3.5) over 1 year, relative to no change in score, were associated with increased odds of suicide. Cumulative financial stressors and declining credit scores had the highest ORs for suicide when adjusting for demographics and, among VA users, marital status and prior psychiatric diagnoses. ORs were lower among VA users than among non-VA users. Conclusions and Relevance:In this case-control study, suicide was associated with financial stressors in the prior 12 months. Incorporating financial stressors into clinical evaluations and safety planning may aid in identifying patients at risk for suicide. Policymakers and researchers could consider strategies to detect and mitigate financial stressors as part of comprehensive suicide prevention efforts.

Importance:US veterans have a higher risk of suicide than the general civilian population. Research suggests that COVID-19 infection is associated with increased risk of suicide attempts or other forms of self-directed violence (SDV) among veterans. Objective:To identify subgroups of veterans with high risk of post-COVID-19 suicide attempts or SDV. Design, Setting, and Participants:This is a retrospective cohort study conducted using data from the Veteran Health Administration (VHA). Participants included VHA enrollees with a first case of COVID-19 between May 1, 2021, and April 30, 2022, residing in the 50 states or Washington, DC. Exposure:COVID-19 infection. Main Outcomes and Measures:The main outcome was a suicide attempt or SDV 12 months after COVID-19 infection. Latent class analysis was used to identify subgroups. Outcome rates and 95% CIs per 10 000 veterans were calculated. Multinomial regressions were used to model outcome risk and marginal risk ratios with 99.5% CIs to compare outcome risk across latent classes. Results:The cohort included 285 235 veterans with COVID-19 and was predominantly male (248 118 veterans [87.0%]) and younger than 65 years (171 636 veterans [60.2%]). Chronic pain (152 788 veterans [53.6%]), depression (98 093 veterans [34.4%]), and posttraumatic stress disorder (79 462 veterans [27.9%]) diagnoses were common. The 12-month outcome rate was 73.8 events per 10 000 (95% CI, 70.7-77.0 events per 10 000). Two latent classes with high rates of suicide attempt or SDV were identified. The first high-risk subgroup (46 693 veterans [16.4%]) was older (34 472 veterans [73.8%] aged ≥65 years) and had a high prevalence of physical conditions (43 329 veterans [92.8%] had hypertension, and 36 824 veterans [78.9%] had chronic pain); the 12-month outcome rate was 103.7 events per 10 000 (95% CI, 94.7-113.3 events per 10 000). The second high-risk subgroup (82 309 veterans [28.9%]) was generally younger (68 822 veterans [83.6%] aged <65 years) with a lower prevalence of physical conditions but high prevalence of mental health conditions (61 367 veterans [74.6%] had depression, and 50 073 veterans [60.8%] had posttraumatic stress disorder); the 12-month outcome rate was 162.9 events per 10 000 (95% CI, 154.5-171.8 events per 10 000), and compared with the lowest risk subgroup, the 12-month risk of suicide attempts or SDV was 14 times higher in this subgroup (risk ratio, 14.23; 99.5% CI, 10.22-19.80). Conclusions and Relevance:In this cohort study of veterans with COVID-19, 2 veteran subgroups with distinct health profiles had high rates of suicide attempts and SDV, suggesting that different groups may require different approaches to suicide prevention after COVID-19.

OBJECTIVE:To evaluate whether Veterans infected with SARS-CoV-2 have an elevated risk for needing mental health emergency care (MHEC) relative to uninfected comparators, as measured by emergency department or urgent care clinic utilization for a mental health diagnosis. DATA SOURCES/EXTRACTION:Data from Veterans Health Administration (VHA), VHA-paid, and Centers for Medicare & Medicaid-paid services were used to identify incident MHEC use within 1 year of infection for Veterans with a SARS-CoV-2 infection and matched comparators. STUDY DESIGN:This was a national, retrospective cohort study that leveraged a target trial emulation framework to examine long-term outcomes of SARS-CoV-2 infection among Veterans enrolled in VHA care. Uninfected comparators were matched based on month of infection, demographic, clinical, and health care utilization characteristics. We calculated cumulative incidence rates per 10,000 persons and utilized Cox regression models to estimate hazard ratios (HR) for MHEC up to one year post-infection. PRINCIPAL FINDINGS:The cohort included 207,968 Veterans with SARS-CoV-2 and 1,036,944 comparators. The 365-day incidence of MHEC use was greater among SARS-CoV-2 patients than comparators (HR = 1.48; 95% CI: [1.44, 1.52]). Patients with SARS-CoV-2 had a higher hazard for MHEC use than comparators in all timeframes analyzed. CONCLUSIONS:SARS-CoV-2 infection was associated with increased MHEC use. Active care coordination with existing mental health treatment providers may help mitigate post-infection mental health distress. Future research should explore specific contextual factors contributing to MHEC, such as gaps in continuity of care.

Recently psychiatrically hospitalized Veterans are at elevated risk for suicide soon after discharge. Social connectedness is a robust protective factor against suicide; however, many Veterans have limited sources of social support and well-being. Promoting engagement in community activities may help increase social connectedness, but there is limited research on the barriers and facilitators experienced by mental health providers, community organizations, and Veterans' loved ones to support such efforts. The current study collected qualitative data via interviews with 29 participants from these three groups in different regions of the United States. Interviews focused on participants' experiences with organizational- and systems-level factors impacting current implementation of strategies for supporting Veteran engagement in community activities. Data were analyzed using templated summarization and matrix analysis. Participants generally valued community engagement for this high-risk population and identified barriers related to mental health challenges and lack of central coordination of activities. Mental health administrators and policy makers invested in increasing social connectedness among high-risk Veteran groups should consider leveraging existing community networks to address identified barriers to community engagement.

Building a positive therapeutic relationship is a challenging, yet critical, first step in conducting youth psychotherapy. A number of studies in the youth treatment literature have indicated that a positive therapeutic alliance is related to increased treatment attendance, participation, and outcome. Some research has examined therapist behaviours for engaging therapy clients; however, developmental differences in alliance formation have had limited exploration. The current study surveyed clinicians about their use of specific engagement strategies and the developmental stage of their youth clients. It was hypothesised that participants would differentially rate the importance of different aspects of therapeutic engagement based upon a youth client's developmental stage and that these would correspond with differences in specific engagement strategies. A total of 64 clinicians with experience treating youth completed the study. The participants completed a questionnaire administered online that asked them to rate the importance of developmental differences to forming a therapeutic relationship and provide example client behaviours from their clinical experience for each developmental stage. Results showed clinicians felt the relative importance of collaboration, advocacy, and trustworthiness increased with age. These differences were also evidenced in the specific strategies clinicians endorsed in relation to each engagement factor across developmental stages. This program of research will eventually aid in the development of new guidelines for engaging clients in youth psychotherapy. In addition, the results may be used to enhance psychotherapy training for those working with children and adolescents.

The ED has been increasingly recognized as a key setting for suicide prevention. Zero Suicide (ZS) is an aspirational goal to eliminate suicide for all patients within a health care system through utilization of best practices. However, there has been limited exploration of ZS implementation within the ED. As ED nurses play an important role in suicide prevention through their close contact with patients at risk for suicide, ZS implementation would benefit from tailored strategies for ED nurse leadership. We describe the ZS framework and provides strategies for nurse leaders to adapt each ZS component in the adult ED.

INTRODUCTION:Few studies have examined county-level hotspots of veteran suicide and associated place-based contributors, limiting development of targeted community-level prevention strategies. The objectives of this national spatial analysis of all veteran suicides were to identify areas of the United States with higher-than-expected veteran suicide rates and determine county-level social and economic characteristics associated with areas of higher risk. METHODS:Using Bayesian hierarchical modeling, county-level standardized mortality ratios for veteran suicide deaths were estimated for time periods 2011-2018, 2011-2014, and 2015-2018. Adjusted relative risk, accounting for community characteristics, for each county was then estimated and associations between community characteristics and veteran suicide risk were examined. Analyses were conducted in 2023-2024. RESULTS:Risk of veteran suicide is predominantly concentrated in the Mountain West and West. Significant predictors of risk across all time periods were per capita number of firearm retailers (2011-2018 relative risk [RR]=1.065 [95% credible interval [CI] 1.030-1.102]), the proportion of residents who moved in the past year (2011-2018 RR=1.060 [95% CI 1.039-1.081]), the proportion of residents who live alone (2011-2018 RR=1.067 [95% CI 1.046-1.089]), the proportion of residents in rental housing (2011-2018 RR=1.041 [95% CI 1.018-1.065]), and the proportion of married residents (2011-2018 RR=0.915 [95% CI 0.890-0.941]). CONCLUSIONS:This study contributes to a comprehensive public health approach to veteran suicide prevention by identifying where resources are needed most, and which place-based intervention targets have the largest potential for impact. Findings suggest that public health efforts to address suicide among veterans should address community-level firearm access and identify ways to alleviate deleterious effects of social fragmentation.

Background Prior research demonstrates that SARS-COV-2 infection can be associated with a broad range of mental health outcomes including depression symptoms. Veterans, in particular, may be at elevated risk of increased depression following SARS-COV-2 infection given their high rates of pre-existing mental and physical health comorbidities. However, few studies have tried to isolate SARS-COV-2 infection associations with long term, patient-reported depression symptoms from other factors (e.g., physical health comorbidities, pandemic-related stress). Objective To evaluate the association between SARS-COV-2 infection and subsequent depression symptoms among United States Military Veterans. Design Survey-based non-randomized cohort study with matched comparators. Participants A matched-dyadic sample from a larger, stratified random sample of participants with and without known to SARS-COV-2 infection were invited to participate in a survey evaluating mental health and wellness 18-months after their index infection date. Sampled participants were stratified by infection severity of the participant infected with SARS-COV-2 (hospitalized or not) and by month of index date. A total of 186 participants in each group agreed to participate in the survey and had sufficient data for inclusion in analyses. Those in the uninfected group who were later infected were excluded from analyses. Main Measures Participants were administered the Patient Health Questionnaire-9 as part of a phone interview survey. Demographics, physical and mental health comorbidities were extracted from VHA administrative data. Key Results Veterans infected with SARS-COV-2 had significantly higher depression symptoms scores compared with those uninfected. In particular, psychological symptoms (e.g., low mood, suicidal ideation) scores were elevated relative to the comparator group (M Infected = 3.16, 95%CI: 2.5, 3.8; M Uninfected = 1.96, 95%CI: 1.4, 2.5). Findings were similar regardless of history of depression. Conclusion SARS-COV-2 infection was associated with more depression symptoms among Veterans at 18-months post-infection. Routine evaluation of depression symptoms over time following SARS-COV-2 infection is important to facilitate adequate assessment and treatment.

BACKGROUND:Implementation strategies can be a vital leveraging point for enhancing the implementation and dissemination of evidence-based suicide prevention interventions and programming. However, much remains unknown about which implementation strategies are commonly used and effective for supporting suicide prevention efforts. METHODS:In light of the limited available literature, a scoping review was conducted to evaluate implementation strategies present in current suicide prevention studies. We identified studies that were published between 2013 and 2022 that focused on suicide prevention and incorporated at least one implementation strategy. Studies were coded by two independent coders who showed strong inter-rater reliability. Data were synthesized using descriptive statistics and a narrative synthesis of findings. RESULTS:Overall, we found that studies most commonly utilized strategies related to iterative evaluation, training, and education. The majority of studies did not include direct measurement of suicide behavior outcomes, and there were few studies that directly tested implementation strategy effectiveness. CONCLUSION:Implementation science strategies remain an important component for improving suicide prevention and intervention implementation. Future research should consider the incorporation of more type 3 hybrid designs as well as increased systematic documentation of implementation strategies. TRIAL REGISTRATION:< de-identified > .

To better understand and prioritize research on emergency care for Veterans, the Department of Veteran Affairs (VA) Health Services Research and Development convened the 16th State of the Art Conference on VA Emergency Medicine (SAVE) in Winter 2022 with emergency clinicians, researchers, operational leaders, and additional stakeholders in attendance. Three specific areas of focus were identified including older Veterans, Veterans with mental health needs, and emergency care in the community (non-VA) settings. Among older Veterans, identified priorities included examination of variation in care and its impact on patient outcomes, utilization, and costs; quality of emergency department (ED) care transitions and strategies to improve them; impact of geriatric ED care improvement initiatives; and use of geriatric assessment tools in the ED. For Veterans with mental health needs, priorities included enhancing the reach of effective, multicomponent suicide prevention interventions; development and evaluation of interventions to manage substance use disorders; and identifying and examining safety and effective acute psychosis practices. Community (non-VA) emergency care priorities included examining changes in patterns of use and costs in VA and the community care settings as a result of recent policy and coverage changes (with an emphasis on modifiable factors); understanding quality, safety, and Veteran experience differences between VA and community settings; and better understanding follow-up needs among Veterans who received emergency care (or urgent care) and how well those needs are being coordinated, communicated, and met. Beyond these three groups, cross-cutting themes included the use of telehealth and implementation science to refine multicomponent interventions, care coordination, and data needs from both VA and non-VA sources. Findings from this conference will be disseminated through multiple mechanisms and contribute to future funding applications focused on improving Veteran health.

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.

Medical record high-risk flags for suicide indicate patients are receiving enhanced care and alert treating providers to patients' high-risk status. Risk of suicide mortality remains high after flag inactivation, suggesting a need to improve inactivation determinations. This study describes variation in flag inactivation documentation, examines whether documentation varies by patient or facility characteristics, and explores the association between inactivation documentation type and subsequent suicide attempts. In a national sample of veterans with a documented suicide attempt who received a high-risk flag for suicide (n = 224), medical record review was used to categorize provider documentation of the rationale and procedures for high-risk flag inactivation. Mixed-effects logistic regression models were used to examine patient and facility characteristics associated with flag inactivation documentation type and to examine the association between documentation type and subsequent suicide attempts. Flag inactivation documentation fell into one of two categories: documentation stating the patient no longer met criteria for the high-risk flag (minimal documentation; n = 98, 43.8%); and documentation that included a review of one or more criteria for high-risk flag inactivation (more than minimal documentation; n = 126, 56.3%). Flag inactivation documentation was not associated with patient or facility characteristics. Veterans with minimal documentation (vs. more than minimal) were more likely to have a suicide attempt after flag inactivation (adjusted odds ratio, AOR = 2.20; 95% CI [1.01, 4.78]; p = .046). Findings suggest a need to better understand flag inactivation procedures in place and to develop a set of standardized procedures to reduce risk of premature high-risk flag inactivation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

OBJECTIVESRates of suicide exposure are high among service members and Veterans and are especially concerning given the link between suicide exposure and subsequent suicide risk. However, to date, it is unclear which individuals who are exposed to suicide are subsequently at high risk for suicide. Latent profile analysis (LPA) can provide information on unique risk profiles and subgroups of service members and Veterans who have higher suicide risk after suicide exposure, which has not yet been empirically studied. The purpose of this study was to utilize LPA to identify subgroups of service members and Veterans who are at the highest risk for suicidal thoughts and behaviors following suicide exposure.METHODSWe analyzed data using LPA from 2570 service members and Veterans (82.1% male, 69.5% White, and 12.1% Latino/a/x) who completed the Military Suicide Research Consortium's Common Data Elements, a battery of self-report suicide-related measures. Psychopathology, substance use, mental health service utilization, interpersonal theory of suicide, and suicide exposure variables were used to validate classes.RESULTSThree latent classes emerged from analyses, one low-risk class and two-high risk classes with differing profile compositions (one primarily differentiated by anxiety symptoms and one differentiated by substance use).CONCLUSIONClass-specific recommendations for suicide prevention efforts will be discussed.

Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk. To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population. We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1–30, days 31–365, and days 1–365. VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators. Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined. 198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1–30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31–365 HR = 1.30 (CI:1.19, 1.43) and days 1–365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1–30 HR = 1.94 (CI:1.51, 2.49), days 31–365 HR = 1.32 (CI:1.20, 1.45) and days 1–365 HR = 1.38 (CI:1.26, 1.51). COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.

Many Veterans at high risk for suicide are identified in Veterans Health Administration (VHA) emergency departments (ED). Little is known about what may predict care utilization in this population. To address this knowledge gap, we explored factors associated with Veterans' lack of VHA care utilization following a positive suicide risk screen in the ED.

This national, observational study examined factors associated with undetermined self-directed violence (SDV) classification among Veterans with a SDV event classified as either "suicide attempt " or "undetermined SDV " in in the Veterans Health Administration (VHA) between 2013 and 2018 (N = 55,878). Generalized estimating equations were used to examine associations of patient and SDV event factors with likelihood of an undetermined SDV classification. Veterans who used poisoning or other methods had 1.52 (95%CI: 1.38, 1.66) and 2.33 (95%CI: 2.16, 2.50) increased odds of having their SDV classified as undetermined, respectively. Veterans with a prior year substance use disorder diagnosis had 1.19 (95%CI: 1.14, 1.24) increased odds of having their SDV classified as undetermined. In sex-stratified analyses, associations of poisoning and substance use disorders held only among males. Additional clinical evaluation of patients with histories of substance use disorders or who use poisoning as method of SDV may be warranted when making SDV determinations.