Abstract
Objective:
Suicide is a leading cause of death in the US, prompting the US Surgeon General to issue a report describing actionable items to reduce suicide rates. This included a recommendation to increase the use of Caring Letters in diverse settings. The intervention consists of mailing brief, non-demanding messages of care. As part of the Department of Veterans Affairs’ efforts to reduce veteran suicide, a Caring Letters project was developed for veterans who call the Veteran’s Crisis Line (VCL). This paper describes results of qualitative interviews conducted with veterans who received Caring Letters to better understand their experiences.
Methods:
Beginning in 2020, all identifiable, veterans who used Veteran Health Administration services and contacted the VCL received nine Caring Letters and a list of mental health resources over the course of one year. Semi-structured interviews were conducted, and content analysis was used to identify veterans’ perspectives and suggestions for improvement.
Results:
Twenty-three veterans participated in semi-structured interviews, 16 men and 7 women, with an average age of 53 years. Feedback varied with most reporting that receiving Caring Letters made a positive impact while others noted aspects that could be improved to enhance the intervention’s caring intent. Some also reported the letters helped them engage in community resources and made them more likely to seek VA care.
Conclusions:
Caring Letters received after contact with the VCL were well received by participants. They described feeling appreciated, cared for, encouraged, and connected. The results of this study will inform future work examining veteran outcomes.
Suicide is a leading cause of death in the United States (US), and rates increased over 30% between 1999 and 2019. The suicide rate for veterans is 57% greater than rates for non-veterans.1 Veterans Crisis Line callers are at increased risk of death by suicide compared to the general veteran population (regardless of reason for call).2 In response to rising suicide rates, the US Surgeon General issued a Call to Action in 2021 that included a recommendation to use Caring Letters when gaps in care may exist, including following crisis line calls.3
Caring Letters (aka Caring Contacts), is an evidence-based intervention for post-acute care that consists of sending brief, non-demanding messages of care and concern over a year.4–7 Caring Letters has primarily taken the form of typed postal mail, including letters,4,5 flat cards mailed in envelopes,8–12 and greeting cards.13 More recently, they have been sent via email14 and text message.15–17 Results of Caring Letters efficacy studies are mixed.6 Some studies demonstrated a reduction in suicidal behaviors4,8,13,15 but others have not.18,19 A meta-analysis indicated a protective effect associated with suicide attempts at 1-year post-initiation of Caring Letters.6 Clinical practice guidelines suggest Caring Letters in addition to usual care after a psychiatric hospitalization for suicidal ideation or suicide attempt.20 The call from the Surgeon General to consider Caring Letters following crisis calls represents a novel adaptation.
To extend the reach of its prevention services, the Department of Veterans Affairs’ (VA) Veterans Crisis Line (VCL) developed a Caring Letters project.21 VCL services are available 24 hours per day, 7 days per week via telephone, text message, and online chat. The VCL serves veterans, active-duty service members, and third parties (with concerns about veterans or active-duty service members). Reasons for contacting the VCL can vary; the most common is mental health related.22 To adapt Caring Letters for this new population, the team, which included Caring Letter experts, drafted messages consistent with the evidence base (e.g., non-demanding, caring) and informed by pilot studies (e.g., veteran preferences).23 The team presented the project and messages to two veteran engagement groups and a VCL veteran staff member for feedback. Their recommendations informed changes made to the final version. Utilizing a centralized mail service, Caring Letters were sent to veterans who called the VCL, identified themselves, and received VA care. Caring Letters became part of VCL usual care and were not discussed in calls, but mailed after the call. In the first 12-months, Caring Letters were sent to over 100,000 veterans from across the US and its territories.21 A formative evaluation indicated that veterans found the intervention helpful, giving them a sense of hope, renewed faith in the VA, and a sense that someone cares.21
The project is being examined in a hybrid effectiveness-implementation24,25 type 1 trial to evaluate the effectiveness of Caring Letters in this population and to identify barriers and facilitators to implementation. Qualitative interviews were conducted with veterans (N=23) receiving Caring Letters to understand their experiences. This paper describes the results of these qualitative interviews.
Methods
Study design.
The larger study design is a pre-post evaluation using a type 1 hybrid effectiveness-implementation approach. The primary goal is to evaluate the effectiveness of Caring Letters on suicide attempts. The secondary goal is to evaluate barriers and facilitators to implementation. This program evaluation project was reviewed by the authorized program office and met criteria for classification as non-research as described in VA policy and therefore institutional review board approval was not required.26
Participants.
Starting June 2020, Caring Letters were mailed to all veterans calling the VCL who identified themselves and used VA services. Veterans were automatically enrolled using the address in the VA electronic health record. All others contacting the VCL (e.g., those using text or chat, concerned friends and family members) were excluded, as were veterans who died prior to mailing. Eligible veterans were identified weekly. Individuals who called the VCL again within 12 months of their enrollment did not receive additional sets of letters.
Caring Letters intervention.
Caring Letters took the form of a flat card mailed in a light-blue envelope, accompanied by a national mental health resource card; see Reger et al.21 for an image of the first card. They were mailed monthly for the first four months and every other month after for one year (Months 1, 2, 3, 4, 6, 8, 10, 12). A card was also mailed on Veterans Day based on veteran feedback.23 Different message content was created for each timepoint; each veteran received the same set of nine cards. Veterans were randomly assigned to receive all their cards from either a clinician or a veteran peer signatory who both worked with the VCL.
Recruitment.
Veterans who had been mailed all nine letters were sent opt-in letters describing the purpose of the evaluation and inviting them to participate in a telephone interview. Veterans were offered $40 compensation to participate. We oversampled women so they comprised 25% of the recruitment sample. Using simple random sampling stratified by sex, in January 2022, the study team sampled 500 veterans who were mailed all 9 letters with a 75:25 weighting (male:female). To avoid overburdening the interview team, opt-in letters were mailed in batches of 50 (38 men, 12 women) every other week until the recruitment goal of 25 participants was met.27 A total of 250 letters were mailed. Twenty-five volunteered to participate and 23 completed telephone interviews; the remaining two individuals did not recall receiving the cards and could not participate. Interviews were completed in March 2022.
Data collection.
The qualitative team included a doctoral-level anthropologist team lead (THA), a research scientist and Army veteran with a background in social work (JAW), and a research scientist and current Air Force Reservist (NDC). All had experience in qualitative evaluation, health services research, and Caring Letters. At the beginning of each interview, the interviewer (THA or JAW) explained data collection procedures, described the participant’s rights to decline to answer questions or end the interview at any time, and obtained consent to audio record. Interviews were conducted with a semi-structured interview guide (see Supplemental File 1) that included three broad domains of interest informed by the goals of the evaluation: 1) the impact of receiving Caring Letters; 2) perspectives about Caring Letters (e.g., likes, dislikes, preference for signatory); and 3) recommendations for improvement.
Analysis.
Audio recordings were transcribed verbatim by a qualitative team member (NDC). Transcripts were analyzed in two phases: 1) two team members (THA, NDC) developed individual templates using content analysis, and 2) the lead (THA) conducted matrix analysis using constant comparison.28 Templates were structured using deductive domains informed by evaluation goals (i.e., perspectives about Caring Letters). A domain of “other” was included to capture unanticipated responses. The team developed inductive categories within each domain reflecting participants’ perspectives (e.g., categories within the domain of general perspectives included sense of being cared for, liked having resources available).29 See Supplemental File 2 for a master template. The lead synthesized data from the 23 individual templates into one participant-by-domain matrix display (i.e., the display showed each participant’s responses in a single row organized by domain columns). Using constant comparison, she identified the full range of responses received for each domain.30 To ensure data collected from interviews were summarized accurately, the two veteran staff members (JAW, NDC) who had conducted or listened to the interviews confirmed that the templates and matrix matched what they had heard.
Results
Interviews were conducted with 23 veterans. Participants included 16 men and 7 women, with an average age of 53 years (range = 25–74). Participants were from 16 different states in the US. They reported their race and ethnicity as White, non-Hispanic (n=13); White, Hispanic (n=2), and Black/African American (n=8). Interview length ranged from 7 to 34 minutes.
Positive impact.
Most participants described that receiving Caring Letters made a positive impact. Participants described feeling appreciated, cared for, supported, connected, encouraged, heard, and seen after receiving the letters. Some described:
“When you go to the mailbox it feels good to actually have something to open up and be acknowledged and to feel seen and to know that someone is thinking of you.” P23
“In the military […] we’re used to having to suck it up and move forward. When you guys reach out to us, I feel like somebody is listening.” P21
Some participants described aspects of Caring Letters that they perceived made a positive impact. Participants expressed that they liked the length of the message, timing of the letters, look and feel of letters and/or envelopes, list of resources, message sentiment, and receiving a special letter on Veterans Day. Two appreciated efforts to ensure privacy and confidentiality (e.g., messages did not include personal information from their VCL contact; came in a private sealed envelope).
Actions taken.
Participants described using the resources from the list provided, sometimes to connect with mental health care. Some indicated that the letters helped them to stay engaged with existing mental health care:
“I used a couple of [the resources]. I saw a psychiatrist and I got to the VA clinic here…” P29
“The card is a reminder to keep in touch with my therapist, which is nice.” P15
Some participants reported keeping at least one of the Caring Letters.
“I did keep them. I think I put one in a photo album.” P29
Changing perspectives.
Some participants expressed that receiving Caring Letters shifted their perspective toward seeking help, VA providers, or the VA in general.
“It felt nice [to get the letters]. It felt like it was an invitation to call back if I needed to, and I would say if I did need to at that time, I would have felt more comfortable making that phone call...” P22
“Yeah, it changes my perspective. I didn’t know that I was going to be communicated with afterward, so that was good.” P15
Dislikes.
Although participants largely noted positive aspects of the letters, some described aspects that detracted from the intervention’s impact. No participants stated dislike of the entire intervention. One participant reported that the number of letters mailed was excessive. Another noted the cards all looked the same, and therefore, they assumed they said the same thing. Similarly, some felt the messages were repetitive and generic.
“[After the first card it seemed less personal because] there wasn’t anything different or saying, ‘How are you doing?’ Or anything like that. It was just ‘Hey, we’re concerned still’.” P14
Two noted that some veterans might feel like their confidentiality was compromised by the mailings (e.g., if an unintended recipient opens the envelope).
“It did cross my mind that if somebody intercepted this… that would be my only concern. It’s such a private matter and if somebody in my family saw this and I didn’t already tell them I was going through that, that’s a really difficult situation.” P22
Preference for signatory.
Participants often could not remember who had signed the letters they received. Some incorrectly recalled having received Caring Letters signed by both a provider and veteran. Participants who could remember the signatory expressed a range of perspectives regarding which signatory would have been the most impactful.
“I would be more comfortable with it coming from doctors.” P28
“Veteran to veteran, I think is a little more meaningful. It’s not one of those things where you feel like they don’t understand… But also, it felt good that your situation got the attention of a doctor or somebody with a little bit more authority.” P23
“It did feel good about receiving that from the VA staff, but I would say it did feel a little more personal to receive it from a peer and I would say it gave me that feeling of being supported, not feeling alone.” P22
Regardless of whether recipients remembered the identity of the signatory, they vividly recalled the impact that receiving Caring Letters had upon them.
“I can’t remember his name. I don’t know [if it was a veteran or clinician]. I just thought it was a friend reaching out to me and it really didn’t matter. It didn’t matter about nationality or religion. It just mattered that this person reached out to me.” P29
Some participants alluded to unexpected benefits of the signatory, such as providing a sense of stability.
“It was the same person and that right there was nice. There was stability that you don’t necessarily have.” P29
Recommendations and feedback.
Participants provided recommendations for making Caring Letters more effective. Recommendations sometimes contradicted other recommendations or the evidence supporting Caring Letters. Recommendations included reducing the frequency of letters, including a follow up call from the VCL, and adding protocols to assess whether a veteran is getting appropriate mental health care. Veterans mentioned that adding calls could potentially increase connection, improve access to care, and ensure privacy. In contrast, other recommendations were to not change the intervention and keep the mailing frequency the same. Some participants recommended varying the envelope color to indicate the card messages were different. Participants had conflicting suggestions regarding the resource card. One wanted the resource information printed on the back of the letter to save paper, while another stated it was nice to have the letter and resources separate. A final recommendation was to vary the signatory, having the first come from a provider and the next from a veteran peer.
“I think they are pretty good the way it is. It is good they send more than one.” P18
“I think after that first one you could send one and then between the 30-to-60-day period send a follow up just to check in. That first note felt good but once you get two, three, four, five, six, it begins to seem like marketing mail.” P21
Discussion
The results of this evaluation present patient perspectives on the use of Caring Letters for individuals after contacting the VCL. Participants discussed the impact of the intervention in terms closely related to the hypothesized mechanisms for Caring Letters.31 Many participants stated that Caring Letters made them feel cared for, supported, connected, and heard. Leading theories of suicide emphasize the negative psychological consequences of isolation and loneliness.32 Although the quantitative results from the evaluation are needed to examine effectiveness, increased feelings of social support are expected to decrease suicide risk. Systematic reviews and meta-analyses suggest Caring Letters can reduce suicide behaviors in other populations.6,20 Additional research is needed to supplement these preliminary qualitative results.
Many participants found Caring Letters useful for supporting mental health needs. Participants described using the information provided to access new mental health services. In the formative evaluation21 and this summative evaluation, many participants described saving some of the Caring Letters or the resources. Some reported a shift in their perspective toward seeking help from the VA. We hypothesize that several mechanisms of the intervention may support increased access to care. The quantitative evaluation will examine the impact of Caring Letters on VA clinical utilization rates.
Participants reported aspects that they disliked, but none disliked the intervention as a whole. This is consistent with the low opt-out rate. In the first year, Caring Letters were mailed to over 102,000 unique veterans; only 36 opted-out.21 Participant dislikes included that the cards looked similar, messages were repetitive or generic, and the number of cards sent was excessive.
It is interesting that veterans often could not recall who they received letters from yet spoke eloquently about how the letters made them feel. This replicates a preliminary finding in the formative evaluation21 and a prior Caring Letters study with veterans.11,12 In both, letters were sent from someone the patient had never met. It is possible that the sentiments communicated in such messages are more important than the signatory. In the current study, preferences for the peer or clinician signatory were mixed. Since veterans were randomized to one of the two signatories, the quantitative evaluation will determine differences in outcomes by signatory.
Participants provided a variety of recommendations and feedback (e.g., use a variety of envelope colors; review the number of mailings), which will be examined in coordination with results from the full evaluation. Feedback on privacy and confidentiality was important. The intervention strives to meet all federal and VA privacy requirements, and veteran acceptability is critical. Some participants appreciated the characteristics of the intervention that promoted privacy, but others questioned the unintended consequences. Most of the cards do not mention the VCL, but the first mailing indicates it comes from a clinician or a peer veteran who works with the VCL. This was judged to be important to explain who they are from and why the veteran is receiving them. While it is illegal to open someone’s mail, the intervention was developed to protect veterans by stating in the first card that veterans contact the VCL for all kinds of reasons including simple needs like VA scheduling questions (as opposed to stating that the recipient called with a mental health crisis). Envelopes with privacy features were used, and veterans have a right to request a confidential communications address for VA mail.
Limitations.
This study has several limitations. Given this project was conducted with the VCL, only VA-using veterans who called the VCL received the intervention. It is unknown how well these results may generalize to users of other crisis lines. As with other programs using postal mail, recipients are limited to those with a mailing address. The results are limited to veterans who received Caring Letters and were willing to participate. Veterans who did not like the intervention may have been less willing to participate in an interview.
Conclusions
Participants described the intervention as having a positive impact, stating they felt appreciated, cared for, encouraged, and connected. Some described using the resources sent and others reported an improvement in their perspective of VA. Dislikes included cards looking alike and repetitiveness of messages. There was no clear preference for a veteran or provider signatory. The results indicate that Caring Letters received after contact with the VCL are well received. Future work will examine the impact of Caring Letters on veteran outcomes (e.g., service utilization, suicidal behavior).
Supplementary Material
Highlights:
This was the first evaluation of veteran perspectives on the use of Caring Letters after contacting the Veterans Crisis Line.
Most of the veterans interviewed reported positive impacts of receiving Caring Letters and provided potential suggestions for improvement.
These results provide insights for future work examining patient outcomes as a result of receiving Caring Letters (e.g., service utilization, suicidal behavior).
Disclosures and acknowledgments:
The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. Dr. Landes is a paid consultant for RAND and UTHealth Houston. Dr. Abraham is a paid consultant with Roche and Strategic Science and Technologies. Dr. Garrido has received grant funding from Arnold Ventures and the Commonwealth Foundation.
Funding:
This work was funded by a VA Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative grant (PEC 18–202) that included funding from QUERI and the Veteran Crisis Line.
Footnotes
The authors report no conflicts of interest
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