What Now?: Experiences of VHA patients following disclosure of suicidal ideation in primary care and mental health settings

Abstract

Objective:

While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings.

Method:

Qualitative thematic analysis using a conventional/directed hybrid approach.

Results:

A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options.

Conclusions:

While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care.

1. Background

Suicide rates have risen by an alarming 30% since 2000 [1], making suicide prevention a national public health priority. Veterans are more likely to die by suicide compared to nonveterans, with an average of 16.8 U.S. veterans dying by suicide each day [2]. The Veterans Health Administration (VHA) has prioritized suicide prevention efforts, employing multiple strategies including population-based (or “universal”) screening for suicidal ideation (SI) and improved mental health staffing [3]. Efforts to expand screening were undertaken based on evidence that a large proportion of people who die by suicide are seen in a variety of clinical settings in months prior to their death [4–6].

In the VHA, the Suicide Risk identification Strategy (Risk ID) includes “universal” screening using the Columbia Suicide Severity Rating Scale Screener (C-SSRS Screener); screening is administered annually or more frequently in primary, ambulatory, urgent, and emergency care settings [7–9]. Disclosure of suicidal thoughts can also occur independently of the screening process, including when patients contact clinicians or staff specifically to seek help for SI. Such thoughts can be described as passive ideation (“I wish I were dead”), more active ideation (“how might I do it?”); intent (“I am going to do it.”) or planning (“I just bought a rope).” [10] Individuals who report suicidal ideation to clinicians or have positive screens receive a comprehensive suicide risk evaluation (CSRE). The CSRE is designed to help clinicians determine level of suicide risk and identify strategies that are tailored to each patient’s level of risk. For example, patients identified as higher risk may be assigned a “high risk” flag in the medical record, offered safety planning, and initial or increased engagement in specialty mental health care [11,12].

Theoretically, the success of screening relies on two key components: 1) patient disclosure of suicidal thoughts, and 2) subsequent patient engagement in follow up care. Previous research suggests that while both patients and staff are generally receptive to screening [13–16], there is evidence that patients are not always forthright about their suicidal thoughts. Factors shown to be associated with reluctance to disclose suicidal thoughts include female gender, Hispanic ethnicity, lower education, lower income, and fears of consequences including involuntary hospitalization [17–19]. There is also some evidence that screening conducted using patient-centered approaches may increase disclosure (e.g., using eye contact, treating the patient as a person, explaining rationale for screening) [13,20,21].

Accurate disclosure by the patient is critical to determining next steps in evaluation and treatment, however, the evidence is both limited and mixed on whether population-level screening is associated with increased engagement with mental health services [22–25]. We recently learned from VHA primary care and mental health staff that once a patient discloses SI, follow-up processes can vary across VHA clinics, with some sites reporting role-confusion among primary care and mental health care staff, risking that some patients get lost in the system [14]. In the current analysis, we build on this work by characterizing patient experiences following disclosure of SI in primary care and mental health settings to better understand potential barriers to treatment after disclosure of SI.

2. Methods

This study was reviewed and approved by the joint Institutional Review Board of the VA Portland Healthcare System and Oregon Health & Science University, where this study took place. All participants provided informed consent.

Interviewees were recruited following participation in a larger study assessing patient perspectives on screening across VHA clinical settings. This larger study used national VHA datasets to identify patients recently screened for SI in multiple clinical settings. Detailed recruitment methods of the larger study have previously been published [13,14,26]. The survey (n = 1722) asked if veterans were interested in a follow-up qualitative interview and 67.4% of respondents expressed interest (n = 1160). Of those who expressed interest, we purposively sampled for clinical setting and screening outcome. To increase participation by women and ethnically diverse veterans, we prioritized recruitment in these groups. The sample was evenly divided by screening outcome (positive and negative) and gender. Sixty interviews were completed via telephone, and veterans received $40 for participation.

All participants (n = 60) had been recently screened for suicidal thoughts in either primary care (n = 28) or mental health (n = 32) settings. While interviews were originally intended to discuss the most recent screening, the semi-structured design of the interview allowed participants to reflect on all past VHA experiences with screening and experiences disclosing SI outside of the screening process. Therefore, we chose to include all veterans in the sample regardless of their most recent screening status, because exclusion of those who recently screened negative would omit what we might learn from veterans’ previous experiences of screening positive or disclosing suicidal thoughts to a provider outside of a screening encounter. Demographic information is available in Table 1.

Table 1.

Participant demographics (n = 60).

	Average	Range
Age	48	24–75
	Frequency	Percent
Gender
Women	30	50.0
Men	29	48.3
Decline	1	1.7
Race
Asian	4	6.7
Black or African American	15	25.0
Multi-racial	7	11.7
White	34	56.7
Ethnicity
Hispanic	8	13.3
Non-Hispanic	52	86.7
Rural/Urban
Rural	16	26.7
Urban	44	73.3

A semi-structured interview guide was informed by our overall study research questions concerning patient perspectives on being screened for suicidal thoughts, including screening sequalae, in primary care and mental health settings (See Appendix A). All interviews were audio recorded and transcribed. Analysis was conducted using Atlas.ti software by four coders: two primary and two secondary. Our interdisciplinary coding team consisted of two research assistants and two experienced qualitative researchers (one sociologist and one social psychologist). Using the interview guide and research questions, the coding team created a draft codebook. Next, they implemented a conventional/directed hybrid approach for thematic analysis [27], and each coder used the initial codebook to independently review three transcripts. Next, they discussed and refined the initial codebook, making amendments to capture categories not previously defined. Team members met weekly to discuss and come to agreement on new code categories. Secondary coding was conducted on 83% (50/60) of the interview transcripts; any differences between primary and secondary coding were brought to weekly team meetings to discuss. The team collectively identified themes based on patterns found throughout the coding process [28].

3. Results

3.1. Overview

Across primary care and mental health settings, veteran interviewees provided many examples of experiencing adequate, if not excellent, response from care providers following disclosure of suicidal thoughts. Importantly, however, veterans also reported experiencing responses that were inadequate and not helpful. Sometimes they would get “lost in the system” and not receive appropriate and timely care options. In some situations, referrals to the Veterans Crisis Line (VCL), a 24-h VHA-administered hotline veterans can access when experiencing mental health distress [29,30], or the emergency department (ED) were cited as helpful, but others did not appreciate those resources, or felt these resources alone were not sufficient to support their needs.

3.2. Many veterans describe examples of excellent system responses following disclosure

Patients often reported experiencing and appreciating the response they received from staff following disclosure of SI. Immediate, or near immediate, access to a mental health provider was often discussed as a positive experience. Following disclosure of suicidal thoughts, one patient described their experience:

I was just sitting in the exam room with the provider and next thing I know here comes, I’m not sure what her position was but she was the one that saw me, within three minutes there was somebody to take me away and go have a little talk. Right there, right there in the facility. I was impressed with that. She was right there…she did a safety plan for me.

Few patients in our sample recalled what specific treatment options that were offered to them following disclosure. However, the patients that did recall appreciated being offered a variety of treatment options, and many felt that providers listened to their treatment preferences. These veterans also reported being able to make decisions about which treatment options to pursue.

Yeah, I asked her about medication in addition to therapy, so she explained playing around with different treatment options, medication treatment options. Changing dosage, changing medications, and so she definitely listened to how I felt about it.

I told him everything that was going on. And he was listening, he paid attention to what I was saying, he asked a couple other questions about me and my life, my history, life, and stuff like that. And then he was like, okay, well there’s a couple of programs and a couple of things that we can refer you to if you want to. He’s like, you don’t have to do it if you don’t want to, but if you want, I can refer you to a therapist that we have through the VA.

She will ask me if I need certain medications. She’ll give me advice on what I could or could not do or what would be best for me if I want to use that advice at that moment. She doesn’t force me to do anything. She always gives me a choice. Unless she feels strongly about something, then she’ll tell me, hey, I’m going to prescribe this for you. This will work for you.

Many of the veterans received ongoing follow-up from VHA staff following disclosure, which was almost universally appreciated in our sample.

The VA called me, they’ve called and checked on me, they still every once in a while just call, she calls and checks on me, make sure to see if I’m doing okay.

I mean when they put me on the high risk [list] all of sudden my phone was blowing up from everyone, from reaching out and making sure I was okay and that support. And then I’ve been getting letters I guess from my doctor, little postcards letting me know I’m cared for and they’re excited that I’m a patient there.

I told her I wasn’t in immediate danger. I was pretty upset, and you know, I told her “Hey, I’m not actually going to do something,” and she ended up checking on me a few days after just to make sure I was okay.

Patients also reported that staff used creative measures, to ensure they got access to care that would meet their specific needs. These were observed more often in rural and outpatient clinics with fewer staff and resources available. For example, a patient described how a primary care provider got them access to a mental health provider even when their designated mental health provider was unavailable.

Once I finally got to the point where I was in tears, she was like, oh crap. Now what do I do? She managed to get somebody to call me while I was still there at the clinic. Actually, it was late afternoon. I sat out in my car, talking to the, I guess, therapist. I don’t know what exactly her title was. And everyone was, I mean, the clinic closed. I mean, it was late afternoon, so pretty much everybody in the clinic left, and I was still on the phone. I mean, it went pretty well. She [the mental health staff member via phone] did help me kind of get out of that immediate funk. Scheduled me for other, you know, to come in for a personal visit.

While this scenario is not ideal, it did demonstrate that the primary care provider persevered and ensured the patient had access to a mental health provider the same day, and the patient reported feeling better.

3.3. Timely follow-up care and perceived empathy from staff were lacking for some patients

While veterans reported many examples of beneficial responses following disclosure of suicidal thoughts, unhelpful scenarios were also described in about equal measure. Follow-up from providers was sometimes slow, and access to mental health services was limited or had long wait times. One patient described how even after a primary care provider tried to help the veteran access same day mental health services, it still took mental health a week to follow up, causing distress.

And so, for that doctor to take a week to call me, I mean are they taking a week to call these people that have combat-related issues? I mean that’s what pissed me off. It’s like, it’s not about me, it’s not about my care it’s about people that are worse off than me… like somebody’s gotta call you within a few hours not a few days.

Patients reported having to coordinate their own follow-up care during times of duress.

But when I really needed help, it was really hard to get someone to return my phone calls, I had to follow-up with them, I called the suicide hotline twice, because I was really in dire straits, but I kept getting, like four or five people will call me about the same thing, but nobody was taking charge to get me into a provider. So it just took like three weeks just to even get someone to say, okay, ‘I’m gonna have this doctor call you’, it was crazy.

Some patients blamed themselves for the lack of follow-up, feeling it was their own responsibility to coordinate their care, due to the perception that the VHA is understaffed.

I know it’s hard to do follow-ups because of the amount of clients that they have to see on a daily basis. So, it was kind of giving everyone a lot of slack just because of knowing the bureaucracy and how it works. So, I wasn’t like hoping that they would’ve called earlier, you know what I mean. I just felt like if I needed something done, I should put in a bit more work on my end.

Patients reinforced that when there is a long time between disclosure and the first mental health appointment, someone should check in with the veteran during that period. Placing the onus of scheduling follow-up care on the patients seemed to create more distress for patients already in crisis, sometimes causing patients to disengage with care.

Veterans also felt that staff sometimes did not convey empathy for their situation, or that they intended to follow-up following a disclosure. In some instances, patients did not feel empathy from staff even when they were being given access to resources, instead feeling criticized.

I felt like they were all taken aback, like they’re not used to somebody being honest about it. And then they start railing off with the, all the resources that are available, you know, and it does kinda feel like now you’re being judged.

This suggests the manner or tone in which patients are provided resources can impact how receptive a patient is to accept help or engage in mental health services.

3.4. Veterans Crisis Line (VCL) and emergency department (ED) referrals can be helpful, but are not adequate

Some veterans in our sample reported that staff sometimes relied too often on referrals to the Veterans Crisis Line [29,30]. While some veterans found the crisis line to be a valuable resource and found the services helpful, others reported that solely providing the hotline number is not a sufficient response to disclosure.

But it to me it doesn’t seem like it was worth their care. [They] was like, “Hey, did you do it? No? Well, don’t forget to call the other hotline if you ever do. Okay, you have the number? You have the refrigerator pad? All right, bye.”

Some reported that calls to the crisis line often led to a welfare check by local police officers, which for some was uncomfortable but ultimately helpful.

Well, there’s been times that I’ve called the crisis line, and they’ve called additional help for me. They called EMS to come to my home to do a welfare check. The police would come with it to do a welfare check, especially if there’s a weapon involved…It was good. I mean, when it first started, it was frustrating, but now, I’m comfortable with it.

However, veterans who feel distrust toward the police may find this more threatening than helpful. One veteran, who explained that he does not get along with people in authority positions, felt the check-ins by police that happened over several days were invasive.

And they kept sending police around for some kind of follow up or some kind of welfare check. I thought it was irrelevant, you know what I mean? I ain’t call nobody. I ain’t botherin’ nobody why do you keep sending these people around here for?

Parallel to concerns about the crisis line, some veterans felt that being told to go to the emergency department (ED) following a disclosure is an inadequate response. One veteran explained that for them, going to the ED meant they were subsequently going to be hospitalized.

I have my psychiatrist or whoever telling me you know ‘if you feel suicidal go to the emergency room’ and you know whatever. And I did that one time, wound up in the hospital but it’s like no we’re not gonna do that again. So it’s like I’m very careful about what I say and how I say it…I’ve told my psychiatrist over and over again you can say whatever you want but I’m not going to the emergency room. You might as well know that upfront.

This experience made this veteran cautious about what to share in subsequent encounters, potentially reducing the chances of receiving appropriate services when needed. While many veterans found the VCL and the ED to be vital resources, some felt that additional treatment options were necessary to fully meet their needs.

4. Discussion

Little is known about what happens in VHA ambulatory settings following disclosure of SI, and this is the first study we have identified that characterizes disclosure sequalae from the perspective of veterans in these settings. Understanding veterans experiences is critical given that veterans are at a higher risk of suicide than the general population [2]. In alignment with primary care and mental health staff perspectives [14], veterans reported helpful examples of system response, usually in facilities with strong primary care and mental health integration, following disclosure. Veterans appreciated when they were given treatment options and were trusted to make decisions about pursuing further services. Empathy and feeling listened to were key attributes to responses veterans found beneficial. Veterans described many examples of VHA staff taking creative measures to ensure they received timely access to treatment. They also described appreciating when staff checked on them following disclosure, which aligns with other research that caring contacts (often postcards) have been found to help veterans feel cared for and connected to the VHA during a crisis period [31]. These findings align with our unpublished survey data indicating that veterans who disclosed SI to primary care and mental health providers largely found responses by their provider to be helpful.

Still, some experiences were not considered helpful, and sometimes precluded veterans getting the care they need. Veterans reported being uncertain about which provider was responsible for following up with them, and this confusion could lead them to getting lost in the system. This is consistent with interviews conducted with staff about suicide risk screening, which suggested some tension between primary care and mental health staff over who ‘owns’ the screening process [14]. Placing the onus of the veteran to navigate the follow-up process was described as challenging by those having adverse mental health experiences. Expressions of empathy by staff for veterans’ distress were sometimes lacking, even when they were providing resources, suggesting that the tone of response matters. Veterans felt that staff over-relied on referring patients to the VCL and the ED, which was sometimes helpful, but not seen as adequate treatment options. While the VCL and ED serve as an essential safety net for veterans experiencing mental health distress, veterans want additional treatment options. Some veterans also described concerning gaps in care. Incidences of long delays in follow up were described, which was unacceptable given the seriousness of their mental health concerns.

Not surprisingly, the types of responses that veterans identified as helpful and unhelpful reinforce the importance of a patient-centered approach to suicide risk screening, evaluation and treatment planning that involves collaborative decision-making between clinicians and patients. A patient-centered approach aims to create a therapeutic relationship built on trust, empathy, and provides patients with a sense of control and involvement in their own care. This is especially important for patients at risk for suicide who may feel overwhelmed and hopeless. Providing veterans at risk for suicide with treatment options and involving them in decision-making may help restore a sense of control and increase motivation for engaging in follow-up care. A patient-centered care approach also recognizes the importance of providing tailored interventions based on the individual’s specific risks and needs. While specific interventions (e.g., VCL and ED referrals, hospitalization) may be warranted for patients who are at high acute risk for suicidal behavior, such interventions may not be appropriate for those at intermediate to low acute risk for suicide. For these veterans, interventions such as safety planning may be especially worthwhile, with evidence demonstrating that the practice can reduce suicidal behaviors in multiple clinical settings [32–34].

Our data suggest that not all veterans who disclose SI are willing to engage with VHA services offered including safety planning and specialty mental health care [11,12]. Some veterans may not be inclined to engage if options are not offered in a respectful, sensitive, and patient-centered manner. Other veterans may be reluctant to engage in these services based on negative treatment experiences in the past. Environments and approaches that foster psychological safety may improve all veterans’ willingness to engage in further services, and trauma-informed approaches may be particularly motivating for women veterans [35]. Outreach and caring contacts during periods of increased risk, may also be beneficial for those who are hesitant to engage in specific services [31]. Our previous work also suggests that some providers experience understandable discomfort when addressing SI [14]; there is some evidence that training clinicians on how to interact with patients experiencing SI can improve self-efficacy and confidence when the scenario arises [36,37].

This study has some limitations that should be noted. Since this study was conducted within the VHA, our data may not reflect the experiences of patients in other health care systems. Our sample was comprised of patients who volunteered following survey completion, which may be biased toward those with stronger opinions about the process. Nonetheless, our data reflected variation in response including neutral experiences. Despite intentionally recruiting veterans recently screened in primary care and mental health settings, the semi-structured format of the interview guide allowed veterans to discuss their experiences with screening and disclosure at the VHA more broadly than their most recent experiences. While this cast a broader net to understand system responses following disclosure, it is difficult to parse out which clinical setting veterans were referring to (either they did not specify or did not recollect when probed). We expect that follow-up experiences vary between primary care and mental health settings but are not clearly delineated in our qualitative data. Further research is needed to understand to what extent these veteran-specific findings are relevant to a general population, especially given the unique treatment needs of veterans compared to nonveterans. The alignment between our findings with patient-centered approaches, however, suggest outcomes for a broader population may be similar.

Our findings illuminate how a health care system responds to veterans who disclose SI in primary care and mental health settings, which is not well understood. In many cases, the VHA is leveraging its robust efforts to integrate primary care and mental health services to provide timely follow-up care to veterans following disclosure. Many veterans were offered multiple treatment options, felt listened to, and experienced empathy from clinical staff. Notably, however, these experiences were not universal, and veterans also described less-thanhelpful responses following a disclosure including perceived lack of empathy, limited treatment options, and delayed follow-ups. To improve patient experience and engagement, more effort is needed to ensure psychological safety during screenings or voluntary disclosures, as well as multiple treatment options, and follow up after disclosure. Some clinicians and front-line staff could benefit from additional training in best practices for suicide prevention screening to increase comfort and self-efficacy, thereby improving patient experience. We summarize clinical recommendations based on these findings in Table 2.

Table 2.

Clinical recommendations.

During patient encounter

If a screening, explain rationale for screening and what might happen after screening. Fully listen to patients and demonstrate empathy. Offer multiple treatment options, without relying solely on a crisis hotline or emergency departments. Allow veterans to lead decision-making about which treatment options to pursue. Empower patients by completing a safety or crisis response plan as clinically indicated. Create clear instructions for follow-up care for the patient; help troubleshoot any potential barriers.

Outside of the patient encounter

Develop clear protocols for communication between primary care and mental health services about patient care following disclosure, including a method of identifying which service will follow-up with the patient and under what circumstances. Create opportunities for clinician and staff training on suicide screening, risk assessment, safety planning, and treatment options and pathways for referral. Follow-up with patient following disclosure and initial phase of evaluation and treatment.