Veterans Crisis Line Callers With and Without Prior VHA Service Use

Health-related outcomes among veterans identified as being at increased risk during a crisis line contact

Research has focused on developing ways to prevent death by suicide, such as 24-hr crisis lines. The purpose of the study was to examine health-related outcomes among individuals using Veterans Crisis Line services who were evaluated to be at increased risk. Among those with identifying information, records were linked with electronic medical record and death data. 36,133 contacts were coded, and 9,010 Veteran contacts were linked to external data. For 3,331 contacts (37.0%), responders initiated a facility transport plan (FTP; self-transport). For 5,325 contacts (59.1%) responders contacted police department (PD) or emergency medical services (EMS) to facilitate transport. Among those with FTPs, 2,876 Veterans (86.3% of arranged FTPs, and 32.0% of all Veteran callers) were noted as arriving at a health care facility, versus 3,324 Veterans (62.9% of PD/EMS contacts and 36.9% of all Veteran callers) involving PD/EMS dispatch. Over 90% of Veterans in the cohort had a Veterans Health Administration (VHA) health encounter in the year prior to their first contact. Of the 769 previously unengaged Veterans, 765 lived for at least 3 months following their first contact, and 639 (83.5%) had a VHA encounter. Among identified Veterans, the age- and sex-adjusted rates for death by suicide, unintentional drug overdoses, and all causes were 370.8, 456.8, and 3,018.4 per 100,000, respectively. Among members of this high-risk cohort, self-transport resulted in arrival at health care facilities more frequently than PD/EMS transport. Although many engaged in some treatment posttransport, death rates remained high. Ongoing efforts are needed to identify novel ways to prevent suicide among this group of Veterans. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Caring Letters Sent by a Clinician or Peer to At-Risk Veterans: A Randomized Clinical Trial

Importance

Caring letters is an evidence-based suicide prevention intervention in acute care settings, but its outcomes among individuals who contact a national crisis line have not previously been evaluated.

Objective

To examine the outcomes of the Veterans Crisis Line (VCL) caring letters intervention and determine whether there are differences in outcomes by signatory.

Design, Setting, and Participants

This parallel randomized clinical trial compared signatories of caring letters and used an observational design to compare no receipt of caring letters with any caring letters receipt. Participants included veterans who contacted the VCL. Enrollment occurred between June 11, 2020, and June 10, 2021, with 1 year of follow-up. Analyses were completed between July 2022 and August 2023.

Intervention

Veterans were randomized to receive 9 caring letters for 1 year from either a clinician or peer veteran signatory.

Main Outcomes and Measures

The primary outcome measure was suicide attempt incidence in the 12 months following the index VCL contact. Incidence of Veterans Health Administration (VHA) inpatient, outpatient, and emergency health care use were secondary outcomes. All-cause mortality was an exploratory outcome. Wilcoxon rank-sum tests and χ2 tests were used to assess the differences in outcomes among the treatment and comparison groups.

Results

A total of 102 709 veterans (86 942 males [84.65%]; 15 737 females [15.32%]; mean [SD] age, 53.82 [17.35] years) contacted the VCL and were randomized. No association was found among signatory and suicide attempts, secondary outcomes, or all-cause mortality. In the analysis of any receipt of caring letters, there was no evidence of an association between caring letters receipt and suicide attempt incidence. Caring letters receipt was associated with increased VHA health care use (any outpatient: hazard ratio [HR], 1.10; 95% CI, 1.08-1.13; outpatient mental health: HR, 1.19; 95% CI, 1.17-1.22; any inpatient: HR, 1.13; 95% CI, 1.08-1.18; inpatient mental health: HR, 1.14; 95% CI, 1.07-1.21). Caring letters receipt was not associated with all-cause mortality.

Conclusions and Relevance

Among VHA patients who contacted the VCL, caring letters were not associated with suicide attempts, but were associated with a higher probability of health care use. No differences in outcomes were identified by signatory.

Trial Registration

isrctn.org Identifier: ISRCTN27551361.

Crisis Lines: Current Status and Recommendations for Research and Policy

OBJECTIVE

The 988 telephone number was established by the National Suicide Hotline Designation Act of 2020 and implemented in July 2022 as a more accessible way to reach the National Suicide Prevention Lifeline. Current financial and training resources, however, are insufficient to ensure effective implementation.

METHODS

To better understand the state of the literature on crisis support lines in light of the 988 transition, the authors summarized research on suicidal and nonsuicidal outcomes of callers, research on other types of crisis support services, and the benefits of text- and chat-based crisis lines.

RESULTS

Overall, existing evidence for the effectiveness of crisis lines has been weak and has primarily focused on short-term improvements in user distress and on user satisfaction. In addition, research on crisis lines specifically targeted to marginalized populations (e.g., sexual minority groups) and on text- or chat-based crisis lines is lacking.

CONCLUSIONS

The policy-focused recommendations derived from this review include the need for additional research on crisis lines, design and evaluation of culturally tailored training for volunteers and staff, and ethical oversight of private data collected from crisis services. Scaling up state-level planning and comprehensive crisis systems is necessary to successfully implement 988 and to fill current training and research gaps.

Encouraging the use of the Veterans Crisis Line among high-risk Veterans: A randomized trial of a Crisis Line Facilitation intervention

The Veterans Crisis Line (VCL) is a core component of VA's suicide prevention strategy. Despite the availability and utility of the VCL, many Veterans do not utilize this resource during times of crisis. A brief, psychoeducational behavioral intervention (termed Crisis Line Facilitation [CLF]) was developed to increase utilization of the VCL and reduce suicidal behaviors in high-risk Veterans. The therapist-led session includes educational information regarding the VCL, as well as a chance to discuss the participant's perceptions of contacting the VCL during periods of crisis. The final component of the session is a practice call placed to the VCL by both the therapist and the participant. The CLF intervention was compared to Enhanced Usual Care (EUC) during a multi-site randomized clinical trial for 307 Veteran participants recently hospitalized for a suicidal crisis who reported no contact with the VCL in the prior 12 months. Initial analyses indicated that participants randomized to the CLF intervention were less likely to report suicidal behaviors, including suicide attempts compared to participants randomized to receive EUC over 12-months of follow-up (χ² = 18.48/p < 0.0001), however this effect was not sustained when analyses were conducted on an individual level. No significant differences were found between conditions on VCL utilization. Initial evidence suggests a brief CLF intervention has an impact on preventing suicidal behaviors in Veterans treated in inpatient mental health programs; however, it may not change use of the VCL. This brief intervention could be easily adapted into clinical settings to be delivered by standard clinical staff.

Veterans Crisis Line Call Outcomes: Distress, Suicidal Ideation, and Suicidal Urgency

INTRODUCTION

This study evaluates the effectiveness of the Veterans Crisis Line on immediate call outcomes (i.e., caller distress, suicidal ideation, and suicidal urgency) for veterans who provide identifying information.

METHODS

Coders rated pre- and post-distress, suicidal ideation, and suicidal urgency for 647 calls from 2019 veteran callers. Intraclass correlation coefficients examined inter-rater reliability. Multilevel generalized linear modeling examined pre-post changes.

RESULTS

Inter-rater reliability was good for distress, excellent for suicidal ideation, and fair for urgency. Callers had 5 times greater odds of a reduction in distress (AOR=5.03, 95% CI=3.98, 6.49), almost 5 times greater odds of a reduction in suicidal ideation (AOR=4.92, 95% CI=3.49, 6.94), and 11 times greater odds of a reduction in suicidal urgency (AOR=11.01, 95% CI=2.72, 44.50) at the end of calls than at the beginning.

CONCLUSIONS

Veterans Crisis Line callers who provide identifying information experience reductions in distress and suicidal ideation during the call. Research is needed to examine the reduction in suicidal urgency because of fair reliability, generalizability of results to other callers, post-call treatment contact and engagement, and risk for suicide attempts and death.

Editorial: Research Will Help Prepare America for the Rollout of Its New Crisis Hotline

In Mathieu and colleagues'¹ recent systematic review, the authors present important research insights about young people who call hotlines, why they call them, the types of services that callers receive, and the quality of this care. Albeit important on its own, it is particularly timely for American practitioners and policymakers. In December 2020, US President Donald J. Trump signed the National Suicide Designation Act of 2020 into law, designating 9-8-8 as the universal telephone number for accessing the national suicide prevention and mental health crisis hotline. In this editorial, I highlight how the insights provided by Mathieu et al.¹ have implications for the rollout of the new 9-8-8 number.

A Brief Mobile-Augmented Suicide Prevention Intervention for People With Psychotic Disorders in Transition From Acute to Ongoing Care: Protocol for a Pilot Trial

BACKGROUND

People with serious mental illnesses (SMIs) are at exceptionally high risk for lifetime suicidal ideation and behavior compared with the general population. The transition period between urgent evaluation and ongoing care could provide an important setting for brief suicide-specific interventions for SMIs. To address this concern, this trial, SafeTy and Recovery Therapy (START), involves a brief suicide-specific cognitive behavioral intervention for SMIs that is augmented with mobile phone interactions.

OBJECTIVE

The primary aim of this pilot trial is to evaluate the feasibility, acceptability, and preliminary effectiveness of the intervention.

METHODS

A 6-month pilot trial with 70 participants with a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, and current active suicidal ideation were randomized to START or START with mobile augmentation. START consists of 4 weekly sessions addressing early warning signs and triggers, symptoms influencing suicidal thinking, and social relationships. Recovery planning is followed by biweekly telephone coaching. START with mobile augmentation includes personalized automated cognitive behavioral therapy scripts that build from in-person content. Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of telephone coaching), and 24 weeks. In addition to providing point estimates of feasibility and acceptability, the primary outcome of the trial was the change in severity of suicidal ideation as measured with the Scale for Suicide Ideation (SSI) and secondary outcome included the rate of outpatient engagement.

RESULTS

The trial is ongoing. Feasibility and acceptability across conditions will be assessed using t tests or Mann-Whitney tests or chi-square tests. The reduction of SSI over time will be assessed using hierarchical linear models.

CONCLUSIONS

The design considerations and results of this trial may be informative for adapted suicide prevention in psychotic disorders in applied community settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03198364; http://clinicaltrials.gov/ct2/show/NCT03198364.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14378.

The Effectiveness of Crisis Line Services: A Systematic Review

Background: Crisis lines are a standard component of a public health approach to suicide prevention. Clinical aims include reducing individuals' crisis states, psychological distress, and risk of suicide. Efforts may also include enhancing access and facilitating connections to behavioral health care. This review examines models of crisis line services for demonstrated effectiveness. Methods: Literature searches of Medline, EMBASE, PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were conducted from January 1, 1990, to May 7, 2018. Experts were contacted, and references were mined for additional studies. Eligible studies provided health- or utilization-related effectiveness outcome(s). Results were graded according to the Oxford Centre for Evidence-Based Medicine and evaluated for risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. Results: Thirty-three studies yielded effectiveness outcomes. In most cases findings regarding crisis calls vs. other modalities were presented. Evaluation approaches included user- and helper-reported data, silent monitoring, and analyses of administrative records. About half of studies reported immediate proximal outcomes (during the crisis service), and the remaining reported distal outcomes (up to four years post-contact). Most studies were rated at Oxford level four evidence and 80% were assessed at high risk of bias. Conclusions: High quality evidence demonstrating crisis line effectiveness is lacking. Moreover, most approaches to demonstrating impact only measured proximal outcomes. Research should focus on innovative strategies to assess proximal and distal outcomes, with a specific focus on behavioral health treatment engagement and future self-directed violence.

How Involved are Non-VA Chaplains in Supporting Veterans?

In terms of supporting veteran populations, little is known of the experiences of chaplains professionally active outside of Department of Veterans Affairs (VA) healthcare settings. The present study looks to examine how involved non-VA chaplains are in supporting veterans as well as their familiarity with the VA. An online survey was distributed in a convenience sample of chaplains, of which n = 39 met the inclusion criterion for this study (i.e., no past or present VA affiliation). The results find that most of the non-VA chaplains encounter veteran service users either on a weekly or monthly basis. Though familiar with VA services, non-VA chaplains were not sure of their veteran service users' VA enrollment status nor did they feel able to adequately advise their veteran service users on VA enrollment. The results suggest that non-VA chaplains actively support veteran populations. Opportunities for enhancing chaplaincy services and VA outreach programs are discussed.