Measuring Associations of the Department of Veterans Affairs' Suicide Prevention Campaign on the Use of Crisis Support Services

Veterans Crisis Line Contacts After the 988 Suicide and Crisis Lifeline Rollout

INTRODUCTION

This study identifies changes in Veterans Crisis Line (VCL) contact volume following the 988 National Suicide Prevention Hotline rollout, and examines changes in contact volume for self-identified Veterans.

METHODS

VCL's Medora database was analyzed from July 2018 to June 2023, fitting linear interrupted time series models to forecast trends after the July 2022 rollout of the 988 Suicide Prevention Hotline. Data analysis was performed from 2023 to 2024.

RESULTS

After the 988 rollout, average monthly VCL contact volume increased by 5,388 contacts (8.2%). The number of contacts self-identifying as Veterans increased by 2,739 (6.2%), while the percentage of self-identifying Veteran contacts who could be linked to VHA records declined by 3.8%.

CONCLUSIONS

The 988 rollout was associated with increased VCL contact volume and broad changes in the profile of users. This underscores the importance of crisis services in adapting to dynamic user needs and highlights the potential of national suicide prevention initiatives to reach diverse populations.

Public Relations as a Factor in the Prevention of Suicide: The Veteran Administrations Crisis Line

This study examines the effectiveness of the Veterans Administration's (VA) public relations and the effectiveness of advertisements of its suicide hotline, which is called the veterans crisis line (VCL). Using the organization-public relations theory (OPR) this study examined whether known failures of VA marketing campaigns for the VCL could be related to public relations factors. This study found that the VA suffers from a negative perception with veterans, and this translated into lower support for the VCL compared to another suicide hotline. This study concludes that ineffective public relations may indeed be a factor in the reluctance of veterans in crisis to call the VCL for life saving mental health support.

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021)

OBJECTIVE

Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations.

METHODS

A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria.

RESULTS

Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding.

CONCLUSIONS

Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

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.

Perceptions of Public Messaging to Facilitate Help Seeking during Crisis among U.S. Veterans at Risk for Suicide

OBJECTIVE

The primary objectives of this study were to (1) examine how veterans at risk for suicide understand and interpret suicide prevention messages, and (2) identify message features that support (or hinder) help seeking behaviors.

METHOD

Individual virtual interviews (N = 40) were conducted from August 2018 to April 2019 with a nationwide sample of veterans who had a recent non-fatal suicide attempt. Participants were exposed to three messages in public circulation that promote help seeking during crisis and an interview guide steered open-ended conversations on the mechanisms of persuasive communication. Interview transcripts were analyzed using a constant comparison analytic strategy in Atlas.ti.

RESULTS

Preferences for particular kinds of messages and features emerged during interviews based on a need for novel, emotionally intense stimuli among veterans. Specifically, messages with solemn themes and darker, more provocative imagery were believed to be particularly potent for engaging those at high risk. Although the goal of promoting help seeking was discernable, actionable steps (crisis line use) were not clearly communicated potentially preventing messages from increasing help seeking behaviors.

CONCLUSION

While messaging was perceived as capable of intervening to promote help seeking, participants reported distinct communication preferences and needs during periods of high risk. Findings underscore the significance of involving those with lived experience to inform the effective design and use of help seeking messaging targeting veterans at risk for suicide.HighlightsPublic messaging (campaigns) is a portable suicide prevention interventionCareful study is needed to effectively communicate help seeking messagesFindings inform the effective use of campaigns with veterans at risk for suicide.

Veteran Perspectives of Barriers and Facilitators to Campaigns Promoting Help Seeking During Crisis

The objective of this paper is to characterize barriers and facilitators reported by U.S. military veterans related to campaigns promoting help seeking during suicidal crisis. Individual telephone interviews (N = 40) were conducted from August 2018-April 2019 with a sample of veterans who had a recent non-fatal suicide attempt. Interview transcripts were analyzed using a constant comparison analytic strategy. Participants reported the four facilitators to message effectiveness: (a) potential reach of specific channels; (b) interruption of suicidal thoughts; (c) normalizing the suicidal experience and help seeking; and (d) modeling desired behavior change. Barriers that hindered campaigns were also identified and include (a) broad messages, (b) challenges in cognitive processing, (c) media avoidance and (d) a boomerang effect. This study underscores the significance of involving those with lived experience to identify factors that may improve or hinder message effectiveness.

Developing and testing Crisis Line Facilitation (CLF) to encourage help-seeking in adults receiving inpatient treatment for a suicidal crisis

Military Veterans are at overall greater risk of suicide than non-Veterans and have experienced increases in rates of suicide that are on par with or exceed those of the general population. The Department of Veterans Affairs has undertaken several initiatives to reduce suicide among Veterans, including the development and expansion of the Veterans Crisis Line (VCL). The VCL has the potential to reduce suicidal behaviors, but it is likely underutilized by high-risk Veterans. This paper describes the development of Crisis Line Facilitation (CLF) a brief intervention, designed to increase use of the VCL in this high-risk population. In a single session, CLF presents psychoeducational information about the VCL, discusses the participant's perceived barriers and facilitators to future use of the VCL, and culminates in the Veteran calling the VCL with the therapist to provide firsthand experiences that may counter negative impressions of the line. The intervention development process, intervention and control condition, and self-reported change indices are presented. Preliminary results (N = 301) suggest Veterans receiving CLF may experience a significant increase in comfort with, and confidence in, using the VCL during future crises compared to those in the control condition.

An Exploration of Barriers to Suicide Prevention Messaging With US Veterans

Background: Communication campaigns offer a portable intervention to effectively reach and engage target populations at risk for suicide including US veterans. Few studies have evaluated such efforts, and still fewer have examined factors that contribute to failed suicide prevention messaging. Aims: We aimed to examine characteristics of suicide prevention messages and persuasive processes that may underlie failed communicative intervention with US veterans. Method: Telephone interviews were completed with veterans (N = 33) from June to September 2016 using a semi-structured interview guide. Interview transcripts were coded by the authors with NVivo using a constant comparison analytic strategy. Results: Several reasons emerged for why suicide prevention messaging may fail to produce intended responses among veterans. Participants identified message features (e.g., language, images, messenger) and communication strategies that may diminish campaign effects. Limitations: Findings are not generalizable, are limited to participants who used VA healthcare and were not suicidal, and are subject to several biases. Conclusion: This work provides initial insights into barriers to effective message use with veterans.

A randomized controlled trial of public messaging to promote safe firearm storage among U.S. military veterans

BACKGROUND

The objectives of this study were to determine whether short-term exposure to firearm safety messaging significantly improved (1) firearm storage practices, and (2) attitudes of safe firearm storage behaviors among U.S. veterans, a group at elevated risk for firearm suicide.

DESIGN

A three-arm, parallel-group RCT was conducted online in the U.S. nationwide from December 2015 to January 2016.

SETTING

A national random sample of U.S. veterans (N = 358) was recruited from the GfK KnowledgePanel, a probability-based internet panel representative of U.S. adults. All study activities were administered online over a three-week study period.

INTERVENTION

Participants were randomized and exposed three times (once per week) to either (a) firearm safety message only (n = 115); (b) firearm safety and mental health promotion messages (n = 133); or (c) active control group exposed to mental health promotion message only (n = 110). Each message was less than two minutes long.

MEASURES

Assessments were completed at baseline (pre-randomization) and at end-of-trial. Changes in awareness of risk for injuries, attitudes/beliefs related to safe storage practices, behavioral intentions, and storage practices were measured using self-reported surveys. Linear mixed effect models with weighted generalized estimating equations were used to test for exposure effects. Analyses were conducted February 2018.

RESULTS

Analyses restricted to those with baseline firearm access (n = 195) identified no significant changes for intentions or safe storage practices across exposure groups. At baseline, participants' attitudes and beliefs were generally supportive of safe firearm storage. The Firearm Safety message yielded small increases in agreement with the concept that secure storage is "important during emotional or stressful times" (0.36; 95% CI = 0.08, 0.64). Other significant changes in awareness and beliefs were found, but across all study conditions.

CONCLUSION

Results reinforce the critical need for considerable research and testing prior to the widespread implementation of public messages to increase the likelihood for desired exposure effects.

Suicide Prevention Media Campaigns: A Systematic Literature Review

Suicide prevention media campaigns are gaining traction as a means of combatting suicide. The current review set out to synthesize information about the effectiveness of these campaigns. We searched four electronic databases for studies that provided evidence on the effectiveness of media campaigns. We focused on studies that described an evaluation of the effectiveness of an entire campaign or a public service announcement explicitly aimed at suicide prevention. We identified 20 studies of varying quality. Studies that looked at whether campaign exposure leads to improved knowledge and awareness of suicide found support for this. Most studies that considered whether campaign materials can achieve improvements in attitudes toward suicide also found this to be the case, although there were some exceptions. Some studies found that media campaigns could boost help-seeking, whereas others suggested that they made no difference or only had an impact when particular sources of help or particular types of help-seeking were considered. Relatively few studies had sufficient statistical power to examine whether media campaigns had an impact on the ultimate behavioral outcome of suicides, but those that did demonstrated significant reductions. Our review indicates that media campaigns should be considered in the suite of interventions that might be used to prevent suicide. Evidence for their effectiveness is still amassing, but there are strong suggestions that they can achieve positive results in terms of certain suicide-related outcomes. Care should be taken to ensure that campaign developers get the messaging of campaigns right, and further work is needed to determine which messages work and which ones do not, and how effective messages should be disseminated. There is an onus on those developing and delivering campaigns to evaluate them carefully and to share the findings with others. There is a need for evaluations that employ rigorous designs assessing the most pertinent outcomes. These evaluations should explore the nature of given campaigns in detail - in particular the messaging contained within them - in order to tease out which messages work well and which do not. They should also take into account the reach of the campaign, in order to determine whether it would be reasonable to expect that they might have their desired effect.

The Use of Theory-Based Formative Research to Design Suicide Prevention Messaging for U.S. Veterans in Midlife

BACKGROUND

Communication campaigns offer a viable mechanism to promote suicide prevention and reinforce mental health for U.S. veterans in midlife, a group with a high suicide burden. However, little empirical investigation of this type of messaging has been conducted, with formative campaign research conspicuously missing from the limited literature.

AIMS

Using the theory of planned behavior as a guide, formative research was conducted to inform the design of suicide prevention messaging by (a) describing and measuring several theoretical constructs among our audience and (b) modeling associations between constructs and intentions to seek help for suicidal behaviors and mental health more broadly.

METHODS

Telephone-based cross-sectional surveys were collected between 2014 and 2016 from a nationally representative sample of veterans with analyses restricted to those aged between 44 and 65 years ( n = 809). Multiple logistic regression was used to identify significant factors associated with intentions to seek help for either suicidal behaviors or mental health.

RESULTS

Perceived behavioral control was one of the largest predictors of intentions to seek help for both suicidal behaviors and mental health concerns. Descriptive norms were also significantly associated with suicide-related intentions. Data further suggest several types of attitudes (i.e., discordant beliefs, stereotypes) to consider when designing messages for this group.

DISCUSSION

This study represents one of the first efforts to document and describe theoretical constructs and their influence on intentions among veterans in midlife to contribute to the development of evidence-based messaging for veterans informed by a conceptual framework.

CONCLUSION

Findings have important implications as the use of communication strategies for suicide prevention grows increasingly popular.

Promoting Help Seeking to Veterans

BACKGROUND

Few studies have considered different messaging strategies that may augment campaign efficacy to generate help-seeking behaviors among populations at increased risk for suicide, mainly US military veterans.

AIMS

Findings are presented from the pilot evaluation of the It's Your Call campaign implemented by the Department of Veterans Affairs (VA). Three messaging strategies (with varying intensity and mix of messages) were compared to explore which best promote use of the Veterans Crisis Line (VCL) among veteran populations.

METHOD

Daily VCL call data were obtained for 10 US cities during 2011-2012 where the campaign was active, and modeled using Poisson regression to identify changes in utilization patterns associated with the implementation of different messaging strategies.

RESULTS

Significant increases in call rates were only evident during the campaign in communities where mixed messages were disseminated. Further, use of mixed messages yielded greater increases in call rates when compared with the other tested strategies. This was an observational study where identification of causal relationships between variables was limited.

CONCLUSION

Findings are encouraging as messaging was associated with help seeking, and they provide insights into strategies that may rapidly promote crisis line use. Results also underscore the need for further research on suicide prevention campaigns and dissemination practices.