Implementation and Early Utilization of a Suicide Hotline for Veterans

Abstract

Suicide crisis lines have a respected history as a strategy for reducing deaths from suicide and suicidal behaviors. Until recently, however, evidence of the effectiveness of these crisis lines has been sparse. Studies published during the past decade suggest that crisis lines offer an alternative to populations who may not be willing to engage in treatment through traditional mental health settings. Given this promising evidence, in 2007, the Department of Veterans Affairs in collaboration with the Department of Health and Human Services’ Substance Abuse and Mental Health Administration implemented a National Suicide Hotline that is staffed 24 hours a day, 7 days a week, by Veterans Affairs clinical staff. We report here on the implementation of this suicide hotline and our early observations of its utilization in a largely male population.

KEY FINDINGS

• ▪Reducing deaths from suicide is an important priority for the VA. Beginning in 2006, the VA implemented several broadly sweeping initiatives to address the public health problem of veteran suicide.

• ▪Successful engagement of veterans, especially men, through use of a suicide hotline, was determined by VA leadership to have the potential to inform system-level changes to facilitate help-seeking behaviors in veterans who are suicidal or in distress.

• ▪We report on descriptive information available from 3 years of operation of the VA’s hotline and discuss implications for future research.

Suicide has been the focus of national attention for more than a decade.^1–4 During this period, a heightened awareness of suicide in the military and in veterans has developed, largely in response to the wars in Afghanistan and Iraq. A Department of Defense task force has underscored the urgent need to address this public health problem in military and veteran populations⁵; the recently established National Action Alliance for Suicide Prevention⁶ has incorporated a work group focused on veterans as a target population for prevention.

The Department of Veterans Affairs (VA) has been on the forefront of this groundswell and has implemented a comprehensive suicide prevention strategy. This strategy includes widescale enhancements for delivery of mental health care, the VA’s National Suicide Hotline, a national network of VA suicide prevention teams, and targeted programs such as safety planning and follow-up for veterans identified as at risk for suicide through both inpatient and outpatient venues.

Historically, efforts have been expended to encourage suicidal individuals to call suicide crisis line telephone centers, without evidence that this approach decreases events of suicide.^7,8 Joiner et al.⁹ noted that because crisis lines offer accessibility during multiple points along the path to suicidal behavior, they are uniquely poised to intervene in this pathway, including when individuals are in immediate danger of taking their own life. In a practical manner, these telephone services offer the opportunity to intervene during a suicidal crisis when no other help may be acceptable or available. Essentially, crisis lines have served as anonymous venues of contact with little or no longer-term follow-up, systematic referrals for case management, or treatment.

Recent evidence has emerged regarding the potential usefulness and effectiveness of suicide crisis lines. King et al.¹⁰ demonstrated that in a small sample of adolescents, suicidality decreased after a call to a suicide crisis line. In studies funded by the Department of Health and Human Services’ Substance Abuse and Mental Health Service Administration (SAMHSA), Kalafat et al.¹¹ and Gould et al.¹² provided data on the reduction in distress of callers to community suicide crisis lines at the end of a call and emphasized the need to conduct more rigorous suicide assessments. Mishara et al.^13,14 provided evidence that responder intervention styles play an important role in the outcome of the call. Despite these encouraging results, studies have reported that callers to suicide crisis lines are predominantly female and that positive effects during the course of the call are more likely to be detected in younger females.^10,12 In summary, suicide crisis lines in the general population thus far have been shown to be most effective for reaching a select population that is younger, female, and at a lower risk for self-harm.

The VA’s population is largely male (representing predominantly Vietnam or returning veterans). Although evidence of the usefulness of suicide crisis lines existed at the time of implementation of VA’s suicide hotline, whether a primarily male veteran population would call a hotline was unknown. The VA’s suicide hotline is both similar to community suicide crisis lines and different in important ways. It is similar in that the hotline responds immediately to veterans in distress; it differs in that all hotline responders are trained clinicians who can access a veteran caller’s electronic medical record regardless of the veteran’s location, and records of the call can be immediately incorporated into the electronic medical record. Most importantly, a consenting veteran can be provided with an appropriate referral within the VA mental health care system.

IMPLEMENTATION OF THE DEPARTMENT OF VETERANS AFFAIRS SUICIDE HOTLINE

In July 2007, the VA partnered with the SAMHSA to become part of SAMHSA’s National Suicide Prevention Lifeline Network (Lifeline; Box 1). The SAMSHA-funded network consists of more than 145 crisis centers nationwide.¹⁵ The partnership between the VA and SAMHSA allows the VA to directly provide services to veterans anywhere in the country with the advantage of training and technological support from Lifeline, including backup services in times of high volume or line outage when calls can be taken by any 1 of Lifeline’s 5 backup centers to the VA’s suicide hotline. The program also adopted the National Suicide Prevention Lifeline Suicide Risk Assessment Standards described in detail by Joiner et al.¹⁶ The VA’s hotline has now been widely promoted through public awareness campaigns, for example, posters displayed on public transportation that convey the message that getting help is a sign of strength (Figure 1).

FIGURE 1—

Poster displayed in public transportation to promote the Department of Veterans Affairs Suicide Hotline.

DEPARTMENT OF VETERANS AFFAIRS (VA) SUICIDE HOTLINE DELIVERY OF CARE

Callers to the National Suicide Prevention Lifeline receive the message that if they are a US veteran or are concerned about a US veteran, they should press “1,” which then routes that caller to the VA’s suicide hotline located at the Canandaigua VA Medical Center in Canandaigua, New York. Utilization of the existing 1-800-273-TALK number and the combined promotional efforts of the VA and the Substance Abuse and Mental Health Service Administration (SAMHSA) maximizes the likelihood that veterans at risk, or their friends and families, will hear about the veterans’ suicide hotline.

An exclusive feature of the VA’s suicide hotline is that concomitantly with the implementation of the hotline, the VA leadership mandated a Suicide Prevention Coordinators Program, which requires that every VA medical facility have a minimum of 1 full-time suicide prevention coordinator. Larger facilities now have teams comprising suicide prevention coordinators, suicide case managers, and administrative support. The VA’s hotline responders provide referrals to these teams for follow-up of all veterans who call the suicide hotline and consent to be contacted. Thus, the hotline does not require veterans to initiate the process of accessing care through the usual means of entry to care, primarily through the VA’s mental health system.

FINDINGS

Since the inception of the VA’s suicide hotline, the percentage of veterans self-identifying as veterans has increased from 30% to just over 60% as of September 30, 2010; the volume of calls as of this time was 171 000. Seventy percent of callers were male veterans, and those who disclosed their age were between 40 and 69 years old. Approximately 4000 referrals were made to the VA’s suicide prevention coordinators as of 2008; there were 16 000 referrals at the end of September 2010. In addition to these referrals, simultaneous referrals were made to diverse programs in the VA, including programs for returning veterans from the wars in Afghanistan and Iraq, programs for women, programs for homeless veterans, and substance abuse services. Community referrals were made for veterans not eligible for care within the VA.

CONCLUSIONS

These are the first data to demonstrate that a population consisting primarily of men is willing to call a suicide hotline and accept follow-up referrals; this finding is unprecedented in the history of suicide hotlines. It also demonstrates that men, especially men in the middle years of life who are at high risk for suicide,¹⁷ can be engaged in an intervention that may result in longer-term treatment owing to intensive follow-up. Moreover, the VA’s hotline consists of trained clinicians, whereas most community hotline responders have little if any training in crisis intervention.¹⁸ Key to evaluating whether the VA’s suicide crisis hotline is an effective component of the VA’s overall comprehensive suicide prevention plan is to (1) describe whether calling the hotline diminishes distress, (2) determine the longer-term clinical outcomes of callers to the hotline, and (3) describe responder intervention behaviors and determine whether intervention styles impact changes in distress during the call and willingness to accept a referral to a VA suicide prevention coordinator. Although it will never be possible for us to know about veterans who do not call the hotline, the VA’s electronic medical record allows tracking of longer-term clinical outcomes of callers to the hotline in a manner not possible in community suicide crisis lines. Therefore, future longitudinal analyses of the hotline data will permit us to identify the relation between risk and precipitating factors for subpopulations of veterans, their degree of suicidal ideation or intent, and their previous or current use of mental health services in the VA. Future analysis will also provide critical information regarding outcomes in highly suicidal veterans or veterans suffering from mental distress resulting from, for example, depression, posttraumatic stress disorder, relationship problems, and substance use disorders.