Dr. Steven Dobscha, a psychiatrist at the VA Portland Health Care System in Oregon and director of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC), said that some of the most significant questions to emerge concern the primary care veterans receive prior to suicide. “We’re particularly interested in primary care,” he said, “because it turns out … probably half of veterans who die by suicide have contact with some type of clinician in the month prior to death – and less than half of these contacts are with mental health clinicians.”

“In VA, we have an incredibly well-organized health system with an infrastructure of suicide prevention coordinators, and a hotline, and ongoing communications about issues like suicide. It means we’re the only system that has a shot at being able to do this study.”

His program’s analyses of health care records, said Dobscha, reveal that veterans who died by suicide had very high rates of depression and substance abuse disorders – which weren’t surprising. But the records also suggested, Dobscha said, “that anxiety disorder other than PTSD and functional decline were two variables that were fairly strong predictors of death by suicide. You’ll hear a lot about primary care providers detecting and treating depression when people endorse suicidal ideation, but there has not been quite as much emphasis in primary care on detection and treatment of anxiety disorders and on helping people cope with functional decline over time.”

VA researchers also recently completed a qualitative study – essentially, asking veterans to describe the experience of undergoing brief standardized suicide risk assessments – that has yielded two important insights: First, that veterans often don’t disclose suicidal ideation due to the sense that doing so will stigmatize them as weak. Second, said Dobscha, “they’re much more likely to talk about having suicidal ideation when they have a trusting relationship with a provider. What this suggests is that the clinician who knows the patient best, and ideally who has an ongoing relationship with the patient, should be the one doing this suicide risk assessment, and probably not another staff member or person who doesn’t really know the veteran.”

 

Suicide Prevention: Intervention and Treatment

 

The data gathered through VA’s suicide prevention initiatives inform the design of new risk assessments and interventions. Because most veterans are not in mental health treatment at the time of suicide, the CoE for Suicide Prevention has adopted what Conner calls a “public health philosophy of suicide prevention. We prioritize interventions that cut across conditions, the things that are very common in veterans but nevertheless confer risk for suicide.” A growing body of research, for example, suggests that conditions such as sleep disturbance and pain increase risk for suicide – a finding that has significant implications for future intervention in primary care.

“We also prioritize interventions that can reach a large population of veterans,” said Conner. “We’ll try to go to veterans who might be at risk, rather than simply rely on their coming to us.” HSR&D has funded a pair of such studies, both focused on primary care and led by Dr. Wilfred Pigeon, the CoE’s chief of Clinical Research, and Dr. Jennifer Funderburk of the VA’s Center for Integrated Healthcare. The first, a pilot study, tests whether a cognitive behavioral therapy intervention for insomnia has any effect on suicidal ideation; the second is a full-scale trial examining the efficacy of behavioral activation treatment for depression and suicidality.

Expanding the reach of suicide prevention efforts beyond the mental health care setting is a recurring theme in VA research: Conner is collaborating with Dr. Tracy Stecker, a psychologist at the White River Junction VAMC in Vermont, on a trial examining the effectiveness of a telephone intervention treatment for veterans who call the national Veterans Crisis Line and are experiencing suicidal ideation. At the Portland VAMC, Dobscha, in a study funded by the Military Suicide Research Consortium, is leading a randomized clinical trial of a smartphone application, the Virtual Hope Box, as an accessory to treatment. The application was developed by the National Center for Telehealth and Technology (T2) at Joint Base Lewis-McChord, Washington.

While much VA research is focused on identifying and reducing suicide risk in primary care and other non-mental health care settings, many veterans, already known to be at a high risk for suicide, receive services at VA mental health centers – and substantial clinical research is aimed at preventing suicide among these veterans. Dr. Peter Britton, a psychologist and investigator at the CoE for Suicide Prevention, is currently evaluating the efficacy of an intervention, called motivational interviewing, that he’s adapted to help psychiatric inpatients choose life and treatment over suicide.

“People who are thinking about suicide are often ambivalent,” Britton said. “They obviously have reasons for thinking about suicide – but they also have reasons for why they haven’t made an attempt yet, why they called 911, why they’re on the inpatient unit.” Inpatient facilities offer an opportunity for treatment, said Britton, “but my concern was that if people are in so much pain that they’re thinking about killing themselves, where are they going to find the energy and motivation they need to engage in treatment?”

Britton’s intervention is composed of three sessions aimed at exploring veterans’ values, beliefs, and reasons for living – and ultimately using that information to help patients commit to life-enhancing and life-sustaining activities, such as treatment. The efficacy of this treatment will be measured in two ways: the severity of suicidal ideation afterward, assessed at one, three and six months; and the veteran’s continued engagement in treatment after discharge from the inpatient facility.

Another clinical trial – a large-scale, three-year effort to study 1,800 veterans from 28 VA medical centers – will be launched in the summer of 2015 to study the effects of the drug lithium on suicidal ideation. According to study chair Dr. Ira Katz, a psychiatrist and senior consultant for the VA’s Office of Mental Health Operations, the idea that lithium might affect suicidality isn’t new. Twenty years of observational studies, he said, have suggested a trend ripe for study: “Among patients with bipolar illness, manic-depressive illness, and possibly among patients with depression, individuals treated with lithium seem to have lower suicide rates than people treated with other medications or other combinations of medications.”

It’s an old hypothesis that hasn’t been tested in a clinical trial yet – but the VA offers a unique opportunity to recruit participants, Katz said. “In VA, we have an incredibly well-organized health system with an infrastructure of suicide prevention coordinators, and a hotline, and ongoing communications about issues like suicide. It means we’re the only system that has a shot at being able to do this study.”

There’s a reason much of VA’s suicide prevention research is aimed at reaching veterans where they are, and at getting them into treatment whenever possible: Evidence suggests its mental health services have helped stem overall increases in veteran suicide rates. A study reported in the spring of 2015 by Dr. Claire Hoffmire of the CoE for Suicide Prevention found that the suicide rates among veterans who used VHA mental health services is lower than among veterans who didn’t.

Over the past eight years, according to Katz, as the VA’s program in suicide prevention has gained momentum, the suicide rates among VHA patients have remained more or less the same. Because suicide rates among other groups in the United States – especially among middle-aged men and veterans who don’t use VHA services – have increased significantly over those years, this relative stability suggests the VA’s efforts may be having a mitigating effect. “Nevertheless,” said Katz, “the fact that the rates haven’t come down is a real call for action and a reason why VA has to do more – and hence a major investment in research in suicide prevention in our system.”

This article first appeared in The Year in Veterans Affairs & Military Medicine 2015-2016 Edition.