National rollout of a brief suicide prevention program for veterans shows high success rates

A recent study published in the journal Psychiatric Services suggests that a brief suicide prevention program is being successfully delivered to at-risk veterans across the Veterans Health Administration. The research provides evidence that patients facing a higher risk of suicide are more likely to complete these safety plans, especially when hospital policies require them. These findings offer insights that can help healthcare systems improve their suicide prevention strategies and ensure more equitable care for all patients.

Suicide rates in the United States have increased by roughly thirty percent over the last twenty years. This growing public health crisis has led healthcare professionals to search for effective ways to help people during moments of intense mental distress. Accumulating evidence suggests that brief behavioral interventions can reduce suicidal actions and save lives. One specific approach is the Safety Planning Intervention, often abbreviated as SPI.

The Safety Planning Intervention is a structured process that involves six distinct steps. A healthcare provider and a patient work collaboratively to identify personal warning signs that a crisis might be developing. They also outline internal coping strategies, social contacts who can offer support, and ways to make the patient’s physical environment much safer. This creates a personalized document that the patient can easily reference before and during a severe mental health crisis.

Gabriela Khazanov, an assistant professor at Yeshiva University and head of the Treatment Access and Engagement Lab, wanted to evaluate how this program was being used. “The VA is very invested in suicide prevention and began a national effort to implement the Safety Planning Intervention (SPI) in 2008,” Khazanov said. “SPI is a brief, six-step intervention in which providers and patients collaboratively identify coping and safety strategies to use before and during suicidal crises.”

Before this research, scientists had not fully analyzed the nationwide rollout of the program across the country. “No studies have yet described this implementation effort or differences in implementation by clinical setting or patient characteristics,” Khazanov noted. “This information is not only important to the VA, but also to other health systems interested in equitable implementation of suicide prevention interventions.”

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To explore these questions, the researchers examined national electronic health records from December 2021 to February 2023. They focused on patients who were screened for suicide risk using a standard questionnaire called the Columbia-Suicide Severity Rating Scale Screener. This brief screening tool helps providers determine if a patient has thought about or planned a suicide attempt over the past month.

Using this screening tool, the authors identified a massive sample of 86,913 veterans who had experienced recent suicidal thoughts or behaviors. This specific group of veterans was classified as being at a moderate risk for suicide by the medical system. The scientists then tracked how many of these patients completed an initial safety plan within thirty days of their positive screening. They also checked if patients simply reviewed an older plan they had already made with their doctor in the past.

The authors found that 44.2 percent of the at-risk veterans completed a completely new safety plan within thirty days of their screening. Another 7.2 percent reviewed a previously created plan with their doctor and decided no changes were needed. Some patients had already completed a plan earlier in the year, while others were offered the intervention but declined to participate. When combining all these distinct categories, the data showed that 69.4 percent of the veterans were officially offered the intervention.

The data showed high levels of engagement with the program on a massive scale. “The VA has been remarkably effective in implementing SPI, 69% of veterans with recent suicidal ideation or behavior were offered the intervention and nearly all veterans mandated by VA policy to complete SPI (a subset of the larger pool of those at elevated risk for suicide) did so within the required time frame (98% of qualifying veterans),” Khazanov told PsyPost.

The delivery of the intervention also matched the clinical needs of the patients. “Patients at higher risk for suicide were more likely to complete SPI, indicating widespread, clinically appropriate adoption of the intervention,” Khazanov explained.

Certain high-risk groups, such as those discharged from the emergency department, are strictly required by policy to complete a safety plan. The high success rate among these specific patients stood out to the research team. “I was surprised by the 98% of veterans who were mandated by VA policy to complete SPI and did so within the required time frame, that’s a near-perfect record!” Khazanov noted.

Most of these safety plans were completed in mental health outpatient clinics or specialized inpatient residential settings. Only a small fraction of the interventions took place in general medical offices or acute care environments. This provides evidence that mental health professionals are primarily taking the lead on delivering this specific intervention within the larger hospital network.

The scientists also examined demographic differences among the patients to identify potential disparities in care. “We also generally did not find systematic disparities in SPI administration to minoritized veterans, suggesting that mandatory screening for suicide risk in VA may improve equitable implementation of interventions to prevent suicide,” Khazanov said. “The message of this paper is that when a health system cares about suicide prevention and implements interventions thoughtfully, these efforts can be successful.”

While the researchers did find that younger, Black, female, Hispanic or Latine, and urban-residing patients were slightly more likely to complete the intervention, the gaps were not large. Khazanov provided context for these findings to prevent misunderstandings. “Most numbers in this paper represent percentages of veterans who completed SPI,” she said. “It is important to note that the sociodemographic differences that we identified were small and likely only significant due to the large sample size (given our use of electronic health records).”

Identifying patients who need help relies heavily on screening tools, which can present a challenge. “We based our evaluation of SPI implementation on patients’ self-reported suicidal thoughts, but we know that many patients are hesitant to report having these thoughts,” Khazanov noted. “It is therefore important to support efforts to determine which patients most require suicide prevention interventions based on characteristics aside from just self-report.”

While the study provides detailed insights into suicide prevention efforts, the authors noted some limitations. “Importantly, we just examined implementation of SPI in VA and not its quality or effectiveness, so we don’t know whether SPI was administered well or whether the implementation efforts described actually decreased rates of suicide,” Khazanov explained.

People should not assume the safety plans were automatically flawless just because they were completed on a computer system. “We only looked at rates of SPI completion, we did not investigate the quality of Safety Plans (i.e., did clinicians do a good job of administering SPI?) nor SPI effectiveness/impact on clinical outcomes (i.e., did SPI implementation lead to fewer suicides or better other outcomes?),” Khazanov said. “We concluded that SPI was consistently and appropriately offered to at-risk veterans, not that SPI implementation was necessarily high quality or impactful.”

Future research will need to look at how these safety plans affect long-term survival rates. “I would really love to see/be involved with efforts to measure the impact of SPI administration on suicides rates and other clinical outcomes,” Khazanov shared.

Expanding on the real-world benefits will guide other hospitals in the future. “While previous research found that SPI paired with telephone follow-up for veterans treated in five VA emergency departments led to a reduction in suicidal behavior, examining the impact of SPI as routinely implemented is critical to helping other health systems determine whether and how to implement SPI for patients at risk for suicide,” Khazanov said.

The study, “National Implementation of Suicide Safety Planning in the Veterans Health Administration,” was authored by Gabriela Kattan Khazanov, Tom Cidav, Matthew Wilson, Christopher B. Roberts, Catherine Barry, James R. McKay, Shari Jager-Hyman, Marianne Goodman, and Joseph A. Simonetti.