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. Author manuscript; available in PMC: 2026 Jan 14.
Published before final editing as: Psychol Serv. 2026 Jan 12:10.1037/ser0001008. doi: 10.1037/ser0001008

Characterizing Mental Health Care Utilization for Veterans with PTSD in the Year After a Suicide Attempt

Kate Clauss 1,2,3, Vanessa C Somohano 1, Benjamin J Morasco 1,2,3, Emily A Young 1, Catherine Medina-Jimenez 4, Lauren M Denneson 1,2
PMCID: PMC12798688  NIHMSID: NIHMS2125404  PMID: 41525403

Abstract

Objective:

The goal of this study was to characterize mental health care utilization, including variables associated with initiation of a PTSD evidence-based psychotherapy (EBP), among veterans with PTSD in the year following a suicide attempt.

Methods:

In a national survey of veterans with a recent suicide attempt, 431 had a diagnosis of PTSD and were included in the present study. Patients completed self-report measures of PTSD symptom severity, stigma, and logistic barriers to care. Mental health utilization data were extracted from the electronic health record. Descriptive statistics were used to characterize mental health care utilization in the year after a suicide attempt and regression analyses were used to identify patient- and health service-related factors associated with PTSD EBP initiation.

Results:

The majority of the sample received eight or more outpatient mental health visits in the year following the index suicide attempt (95.8%); however, only 10.4% initiated a PTSD EBP and even fewer (4.2%) received a minimally adequate treatment dose (e.g., eight or more sessions). PTSD severity, stigma, and logistic barriers to care did not account for significant variance in PTSD EBP initiation. In addition to outpatient psychotherapy, the majority of patients received an antidepressant related medication (90.7%) and a substantial portion experienced subsequent psychiatric hospitalization (46.2%).

Conclusions:

Although the majority of patients received eight or more outpatient mental health visits, few engaged in a PTSD EBP, suggesting that additional work is needed to determine how best to time PTSD treatment in the context of a recent suicide attempt.

Keywords: veterans, suicide, PTSD, mental health care utilization

Despite considerable efforts to address suicidality, suicide rates in the United States (US) have risen nearly every year for the past decade (CDC, 2024), with 1.4 million adults reporting a past year suicide attempt (Ivey-Stephenson, 2022). Veterans have higher rates of suicidal thoughts and behaviors than community members, with 9% reporting current suicidal ideation and 3.9% reporting a lifetime history of suicide attempt (Nichter et al., 2021). The year after a suicide attempt is a particularly high-risk period for suicide death. Meta-analytic data suggest suicide rates of 2.8% in the year after a suicide attempt (Demesmaeker et al., 2022). However, estimated risk varies widely, as one study reports 80% of individuals with a prior suicide attempt die by suicide within a year of that attempt (Bostwick et al., 2016). Posttraumatic stress disorder (PTSD) further compounds risk for suicide as individuals with PTSD, versus those without, are at greater risk for suicidal ideation (Schafer et al., 2022), attempts (Holliday et al., 2020), and deaths (Pompili et al., 2013). As such, it is important to understand factors associated with enhanced mental health engagement after a suicide attempt among individuals with PTSD, as increased service utilization has been demonstrated to decrease suicide risk (Bostwick et al., 2016).

Standard treatment following a suicide attempt often includes a comprehensive assessment, discharge planning, risk-related follow-up, lethal means safety planning, and coordination with other providers (F. Shand et al., 2018). Specific to veterans, the VA Clinical Practice Guideline recommends cognitive behavioral therapy and caring communications via mail or text message (Brenner et al., 2025) and contact with suicide prevention teams has been shown to reduce risk for suicide attempts (Doran et al., 2021). Additionally, some data show that evidence based psychotherapies (EBPs) for PTSD can lead to reductions in suicidal ideation (Cox et al., 2016; Martin et al., 2023) and suicide deaths (Saulnier et al., 2024) among veterans and EBPs may be appropriate for high-risk patients (i.e., those with ideation with moderate-to-high intent to die, a plan, or an attempt in the past three months) provided that stabilization is first achieved through a suicide-focused intervention (Bryan, 2016). Despite agreement that mental health care is necessary to reduce risk of suicide death following a suicide attempt, individuals with a past-year suicide attempt may be no more likely to receive mental health care during this critical period, than those without (Bommersbach et al., 2022). Additionally, an online survey of adults with a recent suicide attempt found that most received an assessment within one week of the attempt, but the majority did not believe they received adequate mental health support overall (F. L. Shand et al., 2018). Finally, in a national sample of US adults, 56.3% reported some form of mental health treatment in the year following an attempt; however, nearly 60% reported zero outpatient mental health visits (B. Han et al., 2014). Existing data tend to focus on service utilization among the general population, without providing specific data on higher risk populations such as those with PTSD or veterans. Service utilization among individuals with suicidal thoughts and behaviors has been shown to be influenced by demographic factors, mental health symptoms, practical barriers, and stigma (J. Han et al., 2018); however, it is less clear how these factors influence PTSD EBP initiation among veterans in the year following a suicide attempt.

This paper examines mental health care utilization and PTSD EBP initiation among a sample of veterans at high risk for suicide during the year after a nonfatal suicide attempt. We characterize the demographic and clinical characteristics and other mental health care utilization of those who initiate EBP and those who do not. We also examine the extent to which demographic and clinical characteristics are associated with EBP initiation, to explore factors contributing to EBP engagement during this critical period.

Methods

This is a secondary analysis of a large, national, prospective cohort study that examined gender differences in suicide risk and resilience among veterans with a recent suicide attempt. Study procedures were approved by the Portland VA Institutional Review Board (IRB) and all patients provided informed consent to participate (for parent study information see [Denneson et al., 2024]).

VHA is a national health care system of over 1200 hospitals and clinics, connected via a national electronic health record (EHR). When a veteran endorses suicidal behavior, their provider completes a Suicide Behavior and Overdose Report, containing the date, description of the event, suicidal intent, overdose information, and an assessment of lethality. Additionally, International Classification of Diseases (ICD)-10 codes are used to indicate the presence of a mental health diagnosis (e.g., PTSD). VHA uses standardized note templates for two PTSD EBPs, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE; Holder et al., 2020), that generate “health factors”, or trackable codes within the EHR describing which treatment components occurred in session, the session number, and the type of therapy administered. Robust use of these templates has been ongoing in VA since 2017 (Shiner et al., 2018), which provide reliable data on EBP visits.

Veterans with a nonfatal suicide attempt (i.e., non-fatal self-directed violence with suicidal intent; Crosby et al., 2011) in the past six months were recruited for the original study between February and December 2019. Our team identified veterans with potential suicidal behavior via Suicide Behavior and Overdose Reports and ICD-10 external cause codes for suicidal behavior (i.e., X70-X83, T14.91, T14.91XA, T14.91XD, and T14.91XS). Suicide attempt status was then confirmed via manual medical record review. Patients were excluded if they were institutionalized (e.g., incarcerated), hospitalized, did not speak English, had dementia, or had a guardian. A stratified random sampling approach was used to recruit roughly equal numbers of male and female patients with similar age and race/ethnicity distributions. Specifically, all eligible female patients were invited to participate and a stratified sample of males (matching the female sample on age and race/ethnicity) were invited to participate. Eligible veterans received a recruitment letter with study information (N = 3368). Those who did not opt out received an information sheet with informed consent and a baseline survey via mail. Of these, 1,000 (570 women, 430 men) returned the survey and enrolled in the study. Those who enrolled in the study differed slightly on age, gender, ethnicity, and frequency of mental health diagnoses compared with patients who did not enroll (Denneson et al., 2024). For the purposes of this secondary analysis, PTSD diagnoses were identified using ICD-10 codes (i.e., F43.10; F43.11; F43.12) in the six months prior to their suicide attempt date. Of the 1,000 study enrollees, 431 patients were diagnosed with PTSD and were included in the current analyses.

Mental health care utilization data were extracted from the Corporate Data Warehouse (CDW), a data repository of VHA EHR data, for the 12-month period after each participant’s index suicide attempt. Mental health visits included all outpatient mental health encounters (i.e., phone contacts, group therapy visits, medication visits with psychiatry or nurse practitioners, and individual assessment or psychotherapy visits). In this high-risk sample already engaged in VHA health care, mental health visit data were highly skewed. We therefore present both the continuous variable and categorical variable in the description of the sample. PTSD EBP initiation, number of sessions, and completion were calculated based on PTSD EBP health factor codes recorded during the 12 months after the index suicide attempt. PTSD EBP initiation was defined as having at least one mental health encounter associated with a Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) psychotherapy session (Holder et al., 2020; Shiner et al., 2018) in the 12 months following the date of the index suicide attempt. The number of unique mental health encounters associated with CPT or PE provided information about the number of PTSD EBP sessions attended. Finally, PTSD EBP completion was defined as receiving a minimally adequate dose of either CPT or PE, (i.e., ≥ 8 sessions within 24 weeks or less; Hoge et al., 2014; Holder et al., 2020; Maguen et al., 2018). Psychiatric hospitalization (yes/no) and receipt of an antidepressant medication (yes/no) in the 12 months following the date of the index attempt were also extracted. Antidepressant medication was categorized as yes if the medical record indicated any outpatient prescription with the following classifications in the 12 months following the date of the suicide attempt: tricyclic antidepressant, antidepressants, monoamine oxidase inhibitory antidepressants, investigational antidepressants, and antidepressants – other. Finally, mental health diagnostic data were also extracted from the CDW using ICD-10 codes for the six months prior to the date of suicide attempt. Diagnoses included alcohol and substance use disorders (yes/no), depressive disorders (yes/no), anxiety disorders (yes/no), bipolar disorder (yes/no), and schizophrenia (yes/no).

Demographic information including gender, age, race/ethnicity, and rurality (i.e., urban/rural) were collected via self-report surveys, which were mailed to patients within 6 months of the index suicide attempt as part of the baseline assessment. Five participants identified as transgender and were grouped with the gender they identify with.

The 20-item Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers et al., 2013) was used to assess PTSD symptom severity. Higher scores indicate greater PTSD symptom severity with scores 33 or higher indicative of probable PTSD (Bovin et al., 2016). The PCL-5 has adequate internal consistency and test-retest reliability (Blevins et al., 2015; present study α = .93). The 5-item Stigma Scale for Receiving Psychological Help (SSRPH; Komiya et al., 2000) was used to measure patients’ perception of how stigmatizing it is to receive psychological treatment, with higher scores indicating greater stigma. The SSRPH has exhibited evidence of adequate internal consistency and construct validity (Komiya et al., 2000; present study α = .90). The Perceived Barriers to Care Scale (Ouimette et al., 2011) assessed factors that prevent patients from seeking VA health care, with higher scores indicating greater barriers. We used the logistic barriers subscale, which has demonstrated adequate internal consistency in past research (Ouimette et al., 2011; present study α = .63).

The sample was divided into those who initiated an EBP for PTSD (i.e., who had one or more sessions of PE or CPT in the year after the suicide attempt) and those who did not. Descriptive statistics were used to characterize demographic characteristics and mental health care utilization based on EBP status. Chi-square difference tests and independent samples t-tests were used to identify significant between groups differences and were performed with SPSS version 29.

Logistic regression was used to examine variables significantly associated with EBP initiation in the 12 months following a suicide attempt. Demographic characteristics (e.g., age, race/ethnicity, gender) were entered as covariates, and PTSD severity, stigma, and logistic barriers to care were used as predictors in separate models. Model significance was determined using a combination of p-values and 95% confidence intervals. Missing data were handled by listwise deletion. Logistic regression was performed in R Studio version 4.2.1.

Results

Descriptive statistics are provided for the full sample and are stratified by those who initiated a PTSD EBP (10.4%, n = 45) and those who did not (89.6%, n = 386) in Table 1. In the full sample (N = 431), 59.9% identified as women, 36.0% identified as men, 0.2% identified as non-binary, and 0.7% were either unsure or refused to answer. Over half the sample identified as non-Hispanic White (60.3%), followed by non-Hispanic Black (18.8%), Hispanic any race (12.1%), non-Hispanic all other races (5.6%). The average age was 44.5 years (SD = 12.5). The sample endorsed clinically significant PTSD symptoms on the PCL-5 (M = 76.3, SD = 15.3, min-max = 23-100). The average score for the SRPH was 11.7 (SD = 4.3, min-max = 5-20) and the Logistic Barriers to VA Healthcare subscale was 11.6 (SD = 3.6, min-max = 7-28).

Table 1.

Sample Demographic and Diagnostic Characteristics

Sample Characteristic Total Sample (N = 431) Initiated PTSD EBP (n = 45) Did Not Initiate PTSD EBP (n = 386) Χ2 or t df p-value
Demographic Characteristics
Age (M, SD) 44.50 12.54 42.60 12.07 44.72 12.59 1.08 429 .283
Gender (n, %) .807 3 .848
 Women 258 59.86 28 62.22 230 59.59
 Men 155 35.96 14 31.11 141 36.53
 Non-Binary 1 0.23 -- -- 1 0.26
 Unsure/Refused to answer 3 0.70 -- -- 3 0.78
 Missing 14 3.25 3 6.67 11 2.85
Race/Ethnicity (n, %) 3.50 3 .320
 Non-Hispanic White 260 60.32 27 60.00 233 60.36
 Non-Hispanic Black 81 18.79 9 20.00 72 18.65
 Non-Hispanic All Other 24 5.57 4 8.89 20 5.18
 Hispanic Any Race 52 12.06 2 4.44 50 12.95
 Missing 14 3.25 3 6.67 11 2.85
Locality (n, %) .05 1 .827
 Urban 309 71.69 31 68.89 278 72.02
 Rural 121 28.07 13 28.89 108 27.98
 Missing 1 0.23 1 2.22 -- --
Mental Health Diagnoses
Anxiety Disorder (n, %) 171 39.68 20 44.44 151 39.12 −.69 429 .491
Major Depressive Disorder (n, %) 295 68.45 36 80.00 259 67.10 −1.77 429 .078
Alcohol or Substance Use Disorder (n, %) 175 40.60 17 37.78 158 40.93 .41 429 .684
Personality Disorder (n, %) 121 28.07 9 20.00 112 29.02 1.27 429 .102
Bipolar Disorder (n, %) 89 20.65 4 8.89 85 22.02 2.07 429 .020
Schizophrenia (n, %) 24 5.57 2 4.44 22 5.70 .347 429 .364
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Note. N = 431. X2 and t-test indicate whether there were differences between those who received EBPs versus those who did not receive EBPs on predictor variables. Bolded p values are significant.

We evaluated between groups differences on demographic, mental health, and utilization variables across veterans who initiated an EBP for PTSD and those that did not. Rates of bipolar disorder varied significantly between groups (χ2[1] = 4.24, p = .04) with 22.0% of veterans who did not initiate a PTSD EBP having a co-occurring bipolar diagnosis, compared to 8.9% among veterans who did initiate a PTSD EBP. The groups did not significantly differ on other demographic or clinical variables (Table 1). Veterans who initiated a PTSD EBP had more outpatient mental health visits overall (t = −4.65, p < .001) in the 12 months following a suicide attempt.

Correlations between key continuous study variables are reported in Table 2 and indicate small positive correlations between PTSD severity and stigma for receiving mental health treatment, and PTSD severity and logistic barriers to VA healthcare. In the 12 months following the index suicide attempt, all patients received at least one outpatient mental health visit (e.g., individual psychotherapy, administrative contacts), with an average of 45.9 contacts (median = 32.0, SD = 39.2, range = 1-221). Because this variable is highly skewed and our sample was recruited from patients engaged in care, we categorized it to aid interpretability and found that 95.8% of participants had eight or more outpatient mental health contacts. Despite this, only 45 of the 431 patients (10.4%) initiated an EBP for PTSD, with 4.2% of patients receiving a minimally adequate dose of treatment (Figure 1). Among patients who initiated an EBP for PTSD, the average number of PTSD EBP sessions attended was 7.1 (SD = 4.9, range = 1-19).

Table 2.

Bivariate Correlations

PTSD Severity Stigma Logistic Barriers to Care
PTSD Severity -- -- --
Stigma .20* -- --
Logistic Barriers to Care .23* .21 --
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Note.

*

p <0.01.

Figure 1.

Figure 1

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Number of PTSD EBP Sessions Attended among Veterans who Initiated an EBP for PTSD (n = 45)

In addition to psychotherapy, 90.7% of patients received a depression-related medication. Regarding psychiatric hospitalizations, 53.8% of the sample had no psychiatric hospitalizations in the 12 months after the index suicide attempt, 29.9% had one subsequent hospitalization, and 16.2% had two or more hospitalizations (range = 0-7).

In the logistic regression models controlling for demographic characteristics, PTSD symptom severity (OR = 1.01, 95% CI: .98, 1.03, SE = .01, p = .57) and stigma (OR = 1.06, 95% CI: .98, 1.14, SE = .04, p = .16) did not account for significant variance in initiation of an EBP for PTSD. The model for barriers to care was significant, such that greater barriers to care were associated with greater likelihood of initiating a PTSD EBP; however, the confidence interval contained one suggesting that this effect should not be interpreted as meaningful (OR = 1.04, 95% CI: 1.00, 1.08, SE = .02, p = .04).

Discussion

The year after a suicide attempt is a critical period, one where individuals with additional risk factors, such as PTSD, may be particularly vulnerable for a recurrence of suicidal behavior. The present study examines mental health care utilization, including PTSD EBP initiation during the 12 months after a nonfatal suicide attempt among veterans with PTSD. Initiation of an EBP for PTSD occurred in a minority of cases (10.4%) with only 4.2% of patients receiving an adequate dose of trauma-focused treatment. PTSD symptom severity and perceived stigma associated with mental health care were not significantly associated with PTSD EBP initiation. Although the model for practical barriers to receiving care was significant, the confidence interval overlapped with one, suggesting that the effect was not meaningful.

Although some prior data suggest that demographic characteristics, mental health symptom severity, stigma, and barriers to care are associated with mental health care utilization in the year after a suicide attempt (J. Han et al., 2018), our findings align with other data suggesting that it may be difficult to predict who receives an EBP for PTSD. Specifically, among returning veterans seeking PTSD treatment, age, gender, race/ethnicity, branch of service, alcohol use, previous psychotherapy, barriers to care, and PTSD service connection were not associated with treatment engagement (e.g., psychotherapy or pharmacotherapy; Komiya et al., 2000). This suggests that targeted recruitment efforts based on demographic characteristics, symptom severity, or stigma, or practical barriers to care may not be warranted.

Few veterans in our sample engaged in an EBP for PTSD during the year after a suicide attempt (10.4%) and fewer still received an adequate dose (4.2%). A study by Maguen and colleagues (2018) suggests that 20.2% of Iraq and Afghanistan Veterans with a PTSD diagnosis, who are engaged in mental health care at the VA, participate in at least one session of PE or CPT. This number was derived using a machine learning approach that scanned individual psychotherapy notes, combined with expert review, to identify PTSD EBP sessions, and had no limitation on timeframe. Our data show lower rates of EBP engagement among a high-risk sample. However, our data were derived from a narrower time frame (12 months versus all time), and used PTSD EBP codes from the VA EHR, rather than scanning any psychotherapy note for PTSD treatment content. Therefore, comparison to Maguen and colleagues’ study should be interpreted with caution. It is important to note that PTSD EBPs are not necessarily the first line of treatment for suicidal behavior. Indeed, a minimum 3-month stabilization period before beginning PTSD treatment after a suicide attempt may be recommended (Bryan, 2016). However, given data showing that PTSD treatment reduces suicidal ideation (Gradus et al., 2013), one might expect PTSD treatment to be part of care for veterans with co-occurring PTSD and suicidal behavior. Additional research is needed to characterize the optimum trajectory of care for veterans with a recent suicide attempt and PTSD and if appropriate, how best to connect veterans to PTSD treatment during this critical period.

The current sample consisted of veterans who endorsed a recent suicide attempt during a VA appointment. In the year that followed, all veterans (100%) received at least one outpatient mental health visit, which may have included administrative contacts, with the large majority (95.8%) receiving eight or more outpatient visits. This is in contrast to 43.0% of adults in the community who do not receive an outpatient mental health visit in the year after a suicide attempt (B. Han et al., 2014). While these data may reflect the fact that we enrolled veterans who were already receiving some type of medical or mental health care at VHA, they suggest that veterans in the VHA may receive more support after a suicide attempt than typical US adults receiving care in community clinics. Indeed, VHA has implemented robust follow up for patients who report a nonfatal suicide attempt, including placement of a patient record flag indicating high risk for suicide, outreach from a suicide prevention coordinator, engagement in safety planning, and mental health treatment (Sall et al., 2019). We were encouraged to find that our data supported the likely implementation of these policies in a high-risk care-connected veteran sample and there may be lessons to be learned from integrated health care systems that could be applied in community settings to support veterans in the year after a suicide attempt.

Regarding study limitations, participants were recruited via a stratified random design to achieve a sample with relatively equal numbers of males and females with comparable age and race/ethnicity make-up, resulting in a sample that was overall younger and had a higher portion of female veterans than is typical of the general veteran population. Further, electronic health record data extraction has several challenges. For example, because we derived PTSD diagnostic status from the CDW during the 6 months before the index suicide attempt, we were unable to determine whether the diagnosis was new or pre-existing. It is possible that veterans exhibited low rates of PTSD EBP initiation and engagement following the suicide attempt because they had already received a course of treatment, whether at the VA or in the community. However, given high rates of PTSD symptoms, this explanation seems unlikely, as it would suggest that many veterans in the present study had an unsuccessful course of treatment. Similarly, health factors extracted from the CDW, although useful for providing insight into service utilization, have limitations. For example, the number of outpatient mental health visits variable included intensive outpatient, individual appointments, as well as phone appointments and brief check-ins. Similarly, the PTSD EBP variable was limited to CPT and PE therapy as these were the only PTSD EBPs with standardized note templates that record health factors. Veterans in this study may have opted to receive a PTSD EBP that does not have standardized note templates. As such, in future research, it will be important to replicate study findings using alternate methods or when additional standardized note templates for other PTSD EBPs are available in the EHR. Further, we cannot know whether PTSD treatment was the primary concern for these participants and additional studies may explore this issue. Finally, we used a cutoff of eight sessions to indicate that an adequate dose of treatment had been received, but data are mixed on the extent to which this is associated with meaningful symptom change (Harper et al., 2024). In future research, it may be important to consider how engagement in a PTSD EBP in concert with suicide prevention services are related to subsequent clinical outcomes, including suicidal thoughts and behaviors.

Despite its limitations, this study provides important information about mental health care utilization and PTSD EBP initiation among veterans with PTSD in the year after a suicide attempt. Few veterans in our sample engaged in a PTSD EBP. This suggests the need for additional research on how to time PTSD treatment for veterans with suicidal behavior to reduce suicide risk and maximize symptom relief.

Public Significance Statement:

Among veterans with PTSD and a past-year suicide attempt, the vast majority received eight or more outpatient mental health visits in the year after the attempt, but few initiated an evidence-based psychotherapy for PTSD. Additional strategies may be needed to determine how best to incorporate PTSD treatment into mental health care following a recent suicide attempt.

Disclosures and Acknowledgements:

The authors have nothing to disclose.

Drs. Clauss, Somohano, Morasco, and Denneson are investigators and Ms. Young is a project coordinator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Healthcare System. This material is based upon work supported by the United States Department of Veterans Affairs, Veterans Health Administration, and VA Health Services Research & Development project # IIR17-131. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or United States government. The funders had no role in any aspect of the research or the decision to publish findings.

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