Overview

Suicide is a devastating outcome of major public health importance. Suicide rates for patients abusing alcohol and other substances, or suffering from other mental health conditions may be elevated. Because suicide prevention is a priority of the Veterans Health Administration, the VA wishes to expand and enhance use of evidence-based prevention or reduction methods. Suicide is a major problem in public health. In the US suicide is roughly the 10th leading cause of death, corresponding to about 30,000 deaths per year. Suicide is now understood as a multifactorial phenomenon, with biological, psychological, and social/environmental risk vulnerabilities and triggers. The majority of suicides - at least 90% by some studies - in the US implicate a psychiatric disorder, usually a mood disorder. US military veterans are a large population with multiple, and often significant risk factors for suicide. The Veterans Health Study, which screened 2160 male outpatients at Boston-area VA clinics, reported depressive symptoms in 31% of the sample, a rate more than twice that of the general population. A study of over 800,000 depressed veterans reported a suicide rate about 7 times higher than the baseline risk in the general population. The same study also showed that substance abuse elevated the suicide risk in depressed veterans. A recent report on the prevalence of mental health disorders in soldiers returning from the current Iraq conflict found clinician-identified mental health problems in 20% of active duty personnel, and in over 40% of National Guard and reserve personnel. Suicide in these newly discharged veterans has also received considerable political and media scrutiny. The main problem confronting those working in suicide prevention is that while the absolute number of suicides in a population is cumulatively quite large, the risk of suicide to any given individual, even those with multiple risk factors, is by relative measures quite small. This problem is illustrated in an example in Gaynes et al. who show that for reasonable assumptions of sensitivity and specificity, a screening test for suicide risk would have a positive predictive value of 0.3% and generate an overwhelming number of false positives. These same factors complicate any attempt at constructing randomized clinical trials of suicide prevention efforts. It is widely recognized that the problem of accurate suicide prediction at the clinical level is currently an intractable one. In spite of the difficulties with prediction, structured approaches to suicide prevention have been developed. The multifactorial nature of the problem of suicide has required the adoption of a multifaceted approach to intervention, combining population-based screening and education, with more targeted efforts for those at above-baseline risk. These methods were reviewed by Mann et al. and their conceptual model will organize the interventions we review in this report. The Key Questions were: Key Question 1. What are the new or improved suicide prevention strategies (e.g. hotlines, outreach programs, peer counseling, treatment coordination programs, and new counseling approaches) that show promise for Veterans? Key Question 2. What solid evidence base supports the most promising strategies? Key Question 3. What evidence is still needed to establish various strategies as the most promising (framed as research questions to guide and focus continued research to expand knowledge regarding the effectiveness of suicide prevention approaches)?

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