Preventing Veteran Suicide: A Landscape Analysis of Existing Programs, Their Evidence, and What the Next Generation of Programs May Look Like

Short abstract

In this study, the authors analyze current and emerging activities to prevent veteran suicide. They introduce the RAND Suicide Prevention Activity Matrix, a framework that organizes current approaches, how they complement each other, how they might change, their evidence for preventing veteran suicide, and why they might (or might not) work. The authors then provide recommendations for organizations that implement suicide prevention strategies.

Abstract

Preventing veteran suicide is a national priority for government, veteran advocacy groups, and the private sector. This attention has led many individuals and organizations to leverage their expertise to create, expand, or promote activities that they hope will prevent future deaths. While the number and array of diverse approaches reflect a nation committed to a common goal, they also can create confusion. Advances in technology also generate questions about the future of veteran suicide prevention.

In this study, the authors analyze current and emerging activities to prevent veteran suicide. They introduce the RAND Suicide Prevention Activity Matrix, a framework that organizes current approaches, how they complement each other, how they might change, their evidence for preventing veteran suicide, and why they might (or might not) work. This framework places 26 categories of activities in a matrix based on whom the activity targets (the veteran directly, those who regularly interact with the veteran, or social influences) and what the activity is intended to accomplish (address social conditions, promote general well-being, address mental health symptoms, provide mental health supports, and prevent suicide crises). Entities committed to preventing veteran suicide and seeking to design evidence-informed, comprehensive suicide prevention strategies will benefit from the framework and evidence reviewed in this study, in addition to the recommendations the authors developed from these data.

Veteran Suicide and the National Response

Since 2001, more than 6,000 U.S. veterans have died by suicide each year. The country has responded with a diverse set of prevention activities funded and implemented by government, nonprofit, and private actors. These efforts reflect a nation committed to a common goal and the potential for creative solutions, but they also can create confusion. Advances in technology and novel (or newfound evidence for existing) pharmacological approaches also generate questions about the future of veteran suicide prevention.

In 2023, members of private industry coalesced to join the movement to prevent veteran suicide with the establishment of Face the Fight, a coalition of corporations, foundations, nonprofits, and veteran-focused organizations that are raising awareness and supporting efforts to prevent suicide. Face the Fight commissioned this study by RAND researchers to provide an analysis of current and emerging approaches to prevent veteran suicide. In this study, we provide a framework that organizes current approaches and describes how they complement each other. We also postulate how existing approaches are changing, their evidence for preventing veteran suicide, and why they might (or might not) work.

Approach

We conducted an analysis of 307 suicide prevention programs, 156 of which were currently operating and 226 that were proposed to two funders to expand existing services or initiate or create new programs. (Many programs currently offering a suicide prevention activity also proposed to expand or create new activities, which is why the number of current and proposed programs is 307 and not 382 [i.e., 156 + 226]). The list of current programs came from a web-scraping exercise in which Boolean keyword search strings were applied to Google searches; proposed programs were identified from lists of applicants to the U.S. Department of Veterans Affairs (VA) Mission Daybreak competition and from Face the Fight grantees. These organizations' suicide prevention activities were categorized across 26 suicide prevention activity categories, including pharmacotherapy, noncrisis psychological counseling, wellness retreats, expressive arts programs, religious or spiritual programming, and support with social determinants of health. These 26 categories were defined iteratively: First, we analyzed a subset of programs to create a preliminary list of activities, then we expanded the list using feedback from experts—notably, members of the Face the Fight Scientific Advisory Committee. We then developed a framework to help organize veteran suicide prevention activities, placed activities within this framework, and further described the current landscape of suicide prevention programs. We then conducted narrative reviews to describe the evidence supporting the 26 categories of suicide prevention activities.

The RAND Suicide Prevention Activity Matrix

Suicide prevention activities, whether currently operating or proposed, fit into the cells of a matrix that we call the RAND Suicide Prevention Activity Matrix (Figure 1). The columns derive from the socio-ecological model (Bronfenbrenner, 1979) and represent whom the activity serves: the veteran directly, those in the community who regularly interact with the veteran (i.e., family, friends, health care providers), or social influences within the veteran's life. Importantly, these columns are nested within each other to represent how social influences at one level affect the activities contained within other levels.

Figure 1.

Cataloging Veteran Suicide Prevention Activities Within the RAND Suicide Prevention Activity Matrix

NOTE: N/A = not applicable.

^a Suicide postvention is a set of activities that attempt to mitigate the risk of suicide and other adverse health outcomes through the provision of supports to those affected by a suicide death (Cerel, Frey, and Maple, 2014).

The rows derive from the disease prevention model and describe what the activity aims to accomplish:

• Primordial prevention addresses social or environmental conditions that affect disease outcomes.

• Well-being activities prevent people from developing mental health conditions or suicidal thoughts, promote wellness, or raise awareness about available resources.

• Mental health activities reduce mental health symptoms, prevent people with mental health symptoms from developing suicidal thoughts, or help those who have suicidal thoughts manage these thoughts.

• Mental health supports are activities that do not directly reduce mental health symptoms but create the conditions for improved mental health treatment outcomes.

• Crisis response consists of interventions that prevent people with suicidal thoughts from attempting to take their lives. There is overlap between crisis response and mental health that is represented by a row with dashed lines—these are activities that largely focus on identifying individuals with suicide risk.

With the cells in this matrix defined, we placed each of the 26 suicide prevention activities within these cells. Activity categories could be contained in multiple cells, and the cells in the column labeled society are mostly empty, as societal activities (for example, laws and other policies) were not part of our environmental scan.

The Current Landscape of Veteran Suicide Prevention

In our landscape analysis, we identified 156 programs currently in operation and aiming to prevent veteran suicide. This is an undercount of programs, as our data were generated through examining lists of applicants to the VA Mission Daybreak competition, Face the Fight grantees, and a web-scraping process. We cannot discern any systematic bias that might arise from these approaches; programs not included in our analysis likely fall within one or more of the 26 categories of suicide prevention activities.

Among current programs, there is a strong focus on those that aim to build social connections and those that offer case management or noncrisis psychological counseling. Many programs offer activities that can be classified under more than one category, and, in fact, programs that offer the suite of activities that include social connections, case management, and noncrisis psychological counseling are common. Veterans are the primary focus of most current programs, but many programs are also offered to family members and friends, often in addition to serving veterans directly. Nonprofit organizations operate most current programs, and just under half of the programs are accessed virtually or via a combination of in-person and virtual access.

The Emerging Landscape of Veteran Suicide Prevention

We identified 226 programs that have been proposed to prevent veteran suicide, some of which seek to expand existing services and others that would be brand new. The most common types of proposed programs are multifunctional digital health platforms (mobile health [mHealth] applications), suicide risk assessment tools, and real-time monitoring. These also commonly occur in tandem with each other—for example, an mHealth application that monitors (actively or passively) mental health symptoms and attempts to detect suicide risk. Veterans and their family members remain the focus of many programs, but fewer proposed activities target services to both veterans and their families. Proposed activities are more frequently being led by for-profit corporations and are more likely to use technological approaches, including virtual services and artificial intelligence.

The Evidence for Veteran Suicide Prevention Activities

Table 1 provides a list of the 26 suicide prevention activities, how we defined these activities, and the evidence supporting each as it relates to key outcomes, which may be suicide outcomes, mental health outcomes, or changes in attitudes or behaviors that are theoretically linked with reducing suicide.

Table 1.

Suicide Prevention Activities, Definitions, and Summary of Evidence

Type of Suicide Prevention Program	Description	Evidence
Community-based suicide prevention initiatives	Engaging local communities to provide support and resources for individuals at risk of suicide	Evaluations of community-based suicide prevention initiatives funded as part of the Garrett Lee Smith Act found reductions in suicide deaths.
Social connection programs	Bringing veterans together, in person or virtually, for shared experiences, bonding, and camaraderie	Social connection programs have not been examined in detail in terms of their effectiveness.
Gatekeeper training	Training non-clinicians to recognize and respond to signs of suicide risk	There is some evidence that gatekeeper trainings change individuals' suicide prevention knowledge and willingness to intervene but modest evidence that these programs change gatekeepers' behaviors or increase relevant referrals.
Case management or care coordination	Connecting veterans with various support services, including mental health resources and peer support networks	There are not many high-quality studies that support case management or care coordination on its own for preventing suicide. The exception is when case management or care coordination is embedded as a part of holistic interventions. For example, collaborative care models for depression treatment have demonstrated some impact on suicide outcomes and include care coordination as a main element in their team-based approach. Case coordination is also an element in the Henry Ford Perfect Depression Care initiative, for which studies have shown a reduction in suicides after a systemwide enhancement to depression treatment.
Multifunctional digital health platforms (mHealth applications)	Offering screening tools via a website or application and connecting users with trained clinicians, peers, or chatbots for support and guidance; also providing a variety of services, including enhanced safety features, virtual support networks, educational resources, and crisis intervention tools	There is variability in the types of mHealth applications that may be used to prevent veteran suicide, but only a few have been evaluated, none of which currently have studies finding evidence of an effect on suicide outcomes. There is evidence that some mHealth applications may reduce mental health symptoms or other symptoms associated with suicidality, including evidence specifically among veterans.
Suicide risk screening and assessment	Using tools to identify people at different levels of suicide risk	Some suicide risk screeners are effective at identifying individuals at risk of suicide; however, they are poor at predicting future suicide risk.
Real-time mental health monitoring systems	Using biometric or other technology (e.g., cell phones, watches, rings, medical records) to monitor potential markers of individuals' mental health status and possibly provide alerts to users or their care teams for intervention when necessary	Some technologies demonstrate a modest ability to detect suicide risk in real time, but no research has yet tied the use of these devices to a reduction in suicide outcomes.
Peer-led mental health programs	Providing crisis and mental health support from peers that aims to link individuals with interventions, as well as to instill hope, inspire recovery, and boost empowerment	There is variety in what constitutes peer support, and findings are mixed on whether peer support programs prevent suicide. There is more information that certain types of peer support can improve certain mental health outcomes but a paucity of information on which specific aspects of peer support succeed, for whom, and in what contexts.
Noncrisis psychological treatment	Providing noncrisis counseling services	Certain types of treatments (collaborative safety planning, cognitive behavioral therapy, and dialectical behavior therapy) show small but positive effects on reducing suicidal thoughts and behaviors, including in studies of veterans. This general group of interventions has also been shown to improve mental health symptoms compared with control groups.
Crisis psychological clinical services	Providing crisis counseling services in person, virtually, and by phone, text, or chat (e.g., suicide hotline); this also includes brief crisis interventions in emergency department or hospital settings and psychological support during police response to suicide risk incidents	Many individuals who used crisis services, such as the Veterans Crisis Line, and agreed to participate in follow-up research interviews indicated that the service aided them in not killing themselves and helped connect them with health and mental health care in the month following contact.
Pharmacotherapy	Administering a drug	Certain medications (e.g., clozapine, lithium) reduce suicidal ideation and behaviors for people living with mental health disorders (including depression, anxiety, insomnia, schizophrenia, and bipolar disorder).
Expressive arts	Actively participating in music, fine arts, visual arts, performance, or other art-based activity	There is insufficient evidence to determine whether expressive arts therapies reduce suicidal thoughts and behaviors. There is some evidence showing a positive impact of expressive arts therapies on mental health outcomes in veteran populations, including posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and quality of life.
Animal-assisted programs	Engaging in activities to care for animals (e.g., training, feeding), time with assistance or support animals, or pet ownership	There is insufficient evidence to determine whether animal-assisted programs reduce suicidal thoughts and behaviors. Canine- and equine-assisted interventions improve PTSD symptoms for veterans, although the studies lack precision on the specific types of interventions or programs that are most promising.
Medical devices	Using an instrument to monitor, treat, or alleviate symptoms of a disorder or disease	Brain stimulation devices or treatments have shown promise in treating various mental health conditions, mostly in patients who are or have grown to be resistant to pharmacological interventions for these types of disorders. More recently, some treatments (i.e., electroconvulsive therapy, repetitive transcranial magnetic stimulation, and vagus nerve stimulation) have been used to reduce suicidality in various populations.
Clinician training	Providing training to clinicians in empirically based methods for suicide prevention, intervention, or general best practices	Suicide prevention trainings for clinicians often increase clinician knowledge, confidence, and intentions to engage in best practices, but few studies have documented a change in clinician therapy practices or corresponding patient outcomes.
Support with social determinants of health	Providing direct support with housing, finances, employment, etc.	Suicide rates are associated with many environmental conditions; thus, addressing these conditions may reduce suicide rates. There is some evidence that anti-poverty programs (such as state-level earned income tax credit programs or increases in the minimum wage) reduce suicides. Direct provision of housing supports may be effective at creating contexts in which suicide-specific counseling may be more effective, but a large experimental study failed to find evidence that Housing First, which provides permanent housing without preconditions and offers choices in the wraparound support services that program participants receive, reduced suicidality.
Means safety	Putting time and space between a person at risk of suicide and the means used to take one's own life (e.g., firearm storage, prescription drug disposal, bridge barrier)	There is little evidence to suggest that existing means restriction efforts have successfully changed the ways in which firearm owners store their firearms or how individuals store potentially lethal medications.
Wellness retreats	Attending an in-person gathering of individuals for a shared experience away	There is limited evidence on the efficacy of wellness retreats as a stand-alone intervention in suicide prevention. However, there is evidence illustrating a reduction in symptoms related to PTSD, depression, and anxiety in veterans who attend wellness retreats. Additionally, positive protective factors, such as resilience and social connection, are cited as positive outcomes of wellness retreats.
Passive entertainment	Passively participating (e.g., being in the audience) in sporting events, concerts, plays, movies, or other forms of entertainment	There is no empirical literature that examines passive entertainment as a suicide prevention strategy.
Post-hospitalization outreach	Contacting individuals following discharge from hospitalization due to suicide risk for the purpose of connecting them to mental health support and other resources they may benefit from	Research on interventions that contact individuals following inpatient psychiatric hospitalization generally suggests that outreach is effective in reducing suicide risk; however, there are other studies that report mixed findings. Models that combine safety planning during an emergency department visit or hospitalization for suicide risk with follow-up outreach have preliminary evidence showing that these programs effectively reduce suicide risk relative to not receiving this intervention.
Suicide postvention	Offering structured support through different phases of suicide loss, including stabilization, grief work, and promoting posttraumatic growth	Suicide postvention appears to be somewhat helpful for facilitating the grief process in the short term and may indirectly reduce suicide risk among bereaved individuals. However, it is not clear whether suicide postvention activities reduce suicidal thoughts and behaviors in the long term.
Media campaigns	Using public messaging (e.g., television, online, radio, flyers, newsprint) to provide information to the general public or target audience with the goal of disseminating knowledge, changing attitudes, or modifying behavior	Media campaigns have demonstrated success primarily in increasing general awareness and knowledge of suicide, more-limited success in changing attitudes, and the least amount of demonstrated success in changing behavior. There is specific evidence that veterans who were exposed to some media campaigns indicated a willingness to use a crisis line and associated behavioral changes.
Gaming	Participating in solitary or collaborative recreational video games	There is evidence identifying associations between collaborative video game play and positive psychological characteristics (e.g., social engagement, belonging), as well as between problematic gaming and suicide risk.
Clinical practice guidelines	Following evidence-based recommendations for diagnosing and treating health conditions that are often developed by health care systems (e.g., VA)	Research examining whether clinical practice guidelines improve care is limited.
Religious or spiritual programming	Engaging with religious beliefs, rituals, or practices or spirituality (search for meaning, purpose, and a sense of connectedness)	Very little research to date moves beyond risk or resilience factors to studies of the actual impact of spiritual or religious components in suicide prevention programs on suicide outcomes.
Physical activity, recreation, or exercise	Participating in exercise or a wellness activity associated with physical movement	There is some evidence that prescribed physical activity may reduce suicide attempts but not suicidal ideation.

Recommendations

Our framing of suicide prevention activities across the nested categories describing whom the activity serves and across the rows describing what the activity aims to accomplish, combined with our examination of the existing and emerging landscape of suicide prevention activities and our review of the evidence, led us to make the following five recommendations.

Recommendation 1. Prioritize Implementation of Evidence-Based Prevention Activities

There are suicide prevention activities with evidence for reducing suicidality that are primed for implementation. These are community-based suicide prevention initiatives, suicide risk assessment, noncrisis psychological treatment, crisis psychological clinical services, and pharmacotherapy (for those with mental health conditions). Successful implementation of evidence-based strategies needs to be strategic in a way that prioritizes sustainability, targeting evidence-based activities to specific settings (e.g., assessing risk in emergency departments) or to specific individuals (e.g., veterans with mental health conditions).

Recommendation 2. When Implementing a Suicide Prevention Activity, Consider the Context in Which the Activity Is Intended to Be Delivered

When investing in a specific suicide prevention activity, organizations should consider the nested contexts in which the activity is intended to occur. For example, screening should be conducted only if there are resources readily available for those who screen positive; mHealth applications need to be released with an implementation plan that ensures that veterans will avail themselves of the platform (a known limitation of current products), and clinician training in evidence-based treatments can be effective only if the systems in which they work can accommodate delivery of these treatments and veterans have access to these trained providers.

Recommendation 3. Conduct a Needs Assessment to Identify Gaps in Suicide Prevention Activities

Comprehensive veteran suicide prevention strategies should be implemented in communities defined by geography (e.g., veterans in San Antonio, Texas) or population (e.g., women veterans). Community-specific needs assessments can help identify where, within communities, there are needs, resources, and gaps. There may be some overlapping strategies for suicide prevention, but different subpopulations of veterans at increased risk of suicide may all have different needs for preventing suicide.

Recommendation 4. Apply Different Thresholds of Evidence When Considering Different Suicide Prevention Activities

Individuals and organizations implementing suicide prevention strategies may see value in investing in novel programs or treatments that lack a robust evidence base. In these instances, they should adopt frameworks for evaluating the balance of potential risks (adverse events) and rewards (lives saved). Figure 2 is an illustrative example of such a framework. In this example, experimental treatments are reserved for those with severe suicidality, and the types of experimental programs are those deemed acceptable: They must have some evidence of a benefit and a low risk of adverse events.

Figure 2.

Illustrative Decision Tree for Funding Suicidality Treatment Based on Group of Interest

Recommendation 5. Invest Strategically in Research That Can Fill Notable Gaps in Knowledge

Strategic research investments can help fund potentially promising programs while ensuring that proposed research addresses common limitations and thus advances science. We highlight seven priorities:

1. performing adequately powered randomized controlled trials with long-term follow-up

2. using designs that link interventions that change knowledge, attitudes, and behaviors to suicide-related outcomes

3. specifying operational definitions and mechanisms of change (particularly for nonclinical programs)

4. investing in precision medicine research

5. disentangling multifaceted interventions

6. promoting sustainability of primordial prevention and general well-being

7. prioritizing ethical considerations for promising avenues of research.

This research was funded through a generous grant from Face the Fight© Charitable Fund and conducted within the RAND Epstein Family Veterans Policy Research Institute.