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The majority of Veterans who died by suicide in 2021 had not recently used Veterans Health Administration (VA) services. A public health approach to Veteran suicide prevention has been prioritized as part of the VA National Strategy for Preventing Veteran Suicide. Aligned with this approach, VA's Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative with both clinical and non-clinical community agencies that serve Veterans. The VA COmmunity LeArning CollaboraTive (CO-ACT) uses a quality improvement framework and facilitative process to support community organizational implementation of evidence-based and best practice suicide prevention strategies to achieve this goal. This paper details the structure of CO-ACT and processes by which it is implemented. This includes the CO-ACT toolkit, an organizational self-assessment, a summary of recommendations, creation of a blueprint for change, selection of suicide prevention program components, and an action plan to guide organizations in implementing suicide prevention practices. CO-ACT pilot outcomes are reported in a previous publication.

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BACKGROUND: Veteran suicide remains a significant issue, as 17.5 Veterans die by suicide each day. The US Department of Veteran Affairs (VA) has implemented a robust suicide prevention program within its integrated behavioural health system. Further, the VA has increasingly contributed to suicide prevention in community settings, where a large proportion of Veterans receive health care and social services. One component integral to preventing suicide among Veterans receiving community services is ensuring that organisations are equipped with the latest evidence-based Veteran-specific suicide prevention strategies. METHODS: The Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative in the Denver/Colorado Springs, CO region, spanning 16 months as a multimodal initiative to integrate community organisations and assist them in implementing Veteran suicide prevention strategies used within VA. Agencies completed social network analysis surveys at baseline (T1), year 1 (T2) and 16 months (T3) to examine social networks, partnerships and collaborations among community organisations and the VA over time. RESULTS: The quantity of learning collaborative relationships increased from 30 at T1 to 41 at T3 while the quality of relationships deepened over time from awareness and cooperative to more coordinated and integrated. CONCLUSION: Improvement in relationship quantity and quality facilitates community organisation engagement in collaborating to strengthen their Veteran suicide prevention programming. Learning collaboratives work with the individual organisation for intraorganisational facilitation of implementing suicide prevention strategies and engage and enhance interorganisational partnerships. This multimodal intervention can engage community organisations and provide a stronger safety net for Veterans at risk for suicide.

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OBJECTIVE: Suicide is a significant public health concern. About 48,000 individuals died by suicide in 2021 in the United States, and approximately one in 100 deaths globally are due to suicide. Continuing efforts in program development and evaluation are vital to preventing suicide. Multiple frameworks have been developed to reduce suicide rates, but they have not been compared to assess their comprehensiveness, nor have their components been classified. METHODS: In 2019, the authors conducted a narrative review of the literature and identified four major frameworks for suicide prevention: the U.S. Department of Veterans Affairs (VA) Suicide Prevention Program, the Defense Suicide Prevention Program of the U.S. Department of Defense, Zero Suicide in Health and Behavioral Health Care, and the technical package developed by the Centers for Disease Control and Prevention. Program components for these frameworks were identified and classified by using two prevention strategy classification systems: the National Academy of Medicine's (NAM's) continuum-of-care model and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) prevention model. RESULTS: The cross-program comparison revealed that no single program included all components of suicide prevention programs. However, the VA program was the most comprehensive in terms of the number of components and their spread across prevention strategy classifications. The programs used few components categorized under NAM's promotion or selective prevention strategy classifications. The SAMHSA prevention strategy classifications of information dissemination, community-based processes, and positive alternatives were also used infrequently. CONCLUSIONS: Organizations, health care systems, and policy makers may use these findings as they develop, improve, and implement suicide prevention programs.

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INTRODUCTION: Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. METHOD: The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. RESULTS: The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. CONCLUSION: Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

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Suicide is a major public health problem that disproportionately impacts veterans in the general U.S. population. Recent analyses indicate that American Indian and Alaska Native (AI/AN) veterans may be two to three times as likely as non-Hispanic White veterans to experience suicidal ideation. Although suicide prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none have been designed or implemented for AI/AN veterans. To address this gap, we conducted a scoping review of suicide prevention programs with the objective of identifying promising strategies and lessons learned to identify promising practices for preventing suicide among AI/AN veterans. We conducted two parallel literature searches-a review of suicide prevention programs for the general U.S. adult population and AI/AN communities. We rated programs on 16 criteria, covering five domains-best practices in suicide prevention, U.S. Department of Veterans Affairs (VA) Office of Rural Health Promising Practice criteria, cultural fit, care coordination, and outcomes. Our findings indicate that many of the VA evidence-based or best practice programs are available system-wide, but none have been tailored for AI/AN veterans or the communities in which they live. Conversely, we found that many culturally specific programs implemented in AI/AN communities were rarely disseminated beyond tribal land and none were specifically developed for veterans. Based upon these findings, and to advance suicide prevention programs for AI/AN veterans, we propose a suicide prevention model that builds upon existing VA infrastructure to disseminate best practices to AI/AN communities and integrate tribal-specific cultural approaches to suicide prevention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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BACKGROUND: American Indian and Alaska Natives (AI/ANs) veterans may be at elevated risk for suicide, but little is known about suicide among this population. METHODS: We conducted a retrospective cohort analysis of AI/AN veterans who received health care services provided or paid for by the Veterans Health Administration (VHA) between October 1, 2002, and September 30, 2014, and who were alive as of September 30, 2003. Age-specific and age-adjusted suicide rates through 2018, per 100,000 person-years (PY) at risk and 95% confidence intervals were computed. RESULTS: Age-adjusted suicide rates among AI/AN veterans in this cohort more than doubled (19.1-47.0/100,000 PY) over the 15-year observation period. In the most recent observation period (2014-2018), the age-adjusted suicide rate was 47.0 per 100,000 PY, with the youngest age group (18-39) exhibiting the highest suicide rate (66.0/100,000 PY). The most frequently used lethal means was firearms (58.8%), followed by suffocation (19.3%), poisoning (17.2%), and other (4.7%). CONCLUSIONS: Results suggest that: (1) suicide is an increasing problem among AI/AN VHA veterans; and (2) younger AI/AN VHA veterans are at particularly high risk and warrant focused prevention efforts. Findings are similar to those observed in general AI/AN population. There is a compelling need to review and strengthen VHA suicide prevention efforts directed towards AI/AN veterans.

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American Indian and Alaska Native (AI/AN) Veterans are at elevated risk for suicide, but currently, no population-based research exists on precursors, including ideation, plans, or attempts. We employed two large national surveys to investigate the occurrence of suicide-related behaviors among AI/AN Veterans. Using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS, 2010-2012) and National Survey on Drug Use and Health (NSDUH, 2010-2015), we compared weighted frequencies of suicide ideation in AI/AN Veterans and non-Hispanic White (NHW) Veterans. Suicide ideation among AI/AN Veterans was 9.1% (95%CI = 3.6%, 21.5%) and 8.9% (95%CI = 1.9%, 15.9%) in BRFSS and NSDUH, respectively, compared to 3.5% (95%CI = 3.0%, 4.1%) and 3.7% (95%CI = 3.0%, 4.4%) for NHW Veterans. Logit analysis suggested higher odds of ideation among AI/AN Veterans in both samples (NDSUH: OR = 2.68, 95%CI = 1.14-6.31; BRFSS: OR = 2.66, 95% CI 0.96-7.38), although sample sizes were small and confidence intervals were wide. Consistent findings from two national samples suggest AI/AN Veterans have more than twice the risk of suicide ideation relative to NHW Veterans. Ongoing efforts include weighing these results together with data on suicide deaths from medical and death records to develop effective suicide prevention approaches in collaboration with AI/AN Veterans and their communities.

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Despite the fact that millions of individuals living in the United States are coping with disabilities associated with traumatic brain injury (TBI), limited work has explored strategies for patient engagement in research among those with such injuries. The Coalition for Recovery and Innovation in Traumatic Brain Injury Care Across the Lifespan (CRITICAL) brought together those living with TBI, caregivers, clinicians, researchers, and advocates with the goal of developing a new patient-centered research agenda. This platform was also used to explore strategies to engage those with moderate to severe TBI in the research process. The CRITICAL was formed of 6 survivors of moderate to severe TBI, 2 caregivers of survivors of moderate to severe TBI, and 8 TBI professionals. The CRITICAL identified 3 priority topic areas: Relationship Quality, Caregiver Needs, and Thriving. Furthermore, strategies associated with Communication, Preparation, and the Environment facilitated research engagement. Employing the strategies outlined in this article is expected to promote patient engagement in clinical research, which can improve patient-centered interventions and outcomes for individuals living with TBI.

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OBJECTIVE: The purpose of this study was to develop a conceptual model of community-based veteran peer suicide prevention. METHOD: We conducted a qualitative study in which semi-structured interviews were followed by three focus groups. Participants (n = 17) were chosen from community-based organizations who had peers working on veteran suicide prevention; the sample included veteran peers, non-peers, program managers, and community stakeholders. Interview data were analyzed thematically and inductively to identify key components and subcomponents of veteran peer suicide prevention. A draft model was shared with each focus group to elicit feedback and refine key concepts. RESULTS: A conceptual model containing nine components and twenty-six subcomponents was developed. Participants emphasized key organizational, relational, and practical elements needed to achieve positive outcomes. In addition, they described critical contextual and cultural factors that impacted veteran peers' ability to prevent suicide and promote overall wellness. CONCLUSIONS: Community-based veteran peer efforts are a promising public health approach to preventing veteran suicide. Provided veteran peers are supported and fully allowed to contribute, these efforts can complement existing clinic-based efforts. Future research on community-based veteran peer suicide prevention should document a range of outcomes (e.g., clinical, wellness, financial) and allow for considerable flexibility in peer approaches.

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OBJECTIVE: To develop and use planning maps to prioritize and facilitate county-level recruitment for Together With Veterans (TWV), community-based rural Veteran suicide prevention program. METHOD: Choropleth maps were created for 49 U.S. states, with four mutually exclusive categories indicating eligibility for the TWV program and increasing levels of need assigned to each county based on (a) percent Veterans Health Administration enrollees residing in rural communities, (b) percent population that are Veterans, and (c) crude suicide mortality rate. RESULTS: Of 3113 counties, 78.2% were eligible for TWV and 25.8% met our highest priority definition. A national map and state map were provided to demonstrate final products used to engage stakeholders. A table of recommendations for creating and using planning maps was provided for future projects to reference. CONCLUSIONS: Geographic information system (GIS) is useful for identifying and prioritizing counties that may benefit most from a rural Veteran suicide prevention program. Choropleth maps allow for dissemination of information about county suicide risk and need for suicide prevention to community members, researchers, and others with a vested interest in suicide reduction. The maps are one tool among many which can support decision-makers in focusing available resources on populations with the most need.

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PURPOSE: Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk. METHODS: OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment. FINDINGS: Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use. CONCLUSIONS: Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

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BACKGROUND: While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years. OBSERVATIONS: Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in. CONCLUSIONS: PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

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BACKGROUND: Rural veterans are at increased risk for dying by suicide compared with urban veterans, yet interventions for preventing suicide among rural veterans have been limited. OBJECTIVES: (1) Describe how Together With Veterans (TWV), a community-based intervention to prevent suicide among veterans in rural communities, aligns with the VA National Strategy for Preventing Veteran Suicide; (2) share lessons learned while beginning to implement TWV in rural communities. METHODS: Together With Veterans is being implemented in four rural communities and comprises six suicide prevention best practices: (1) reducing stigma and promoting help-seeking; (2) lethal means safety, with an emphasis on firearms; (3) gatekeeper training; (4) training primary care providers; (5) improving access to crisis services; and (6) enhancing support for high-risk veterans. RESULTS: Together With Veterans best practices align with most, but not all, of the strategies in the VA National Strategy for Preventing Veteran Suicide. Community veteran partners have shown a willingness to collaborate and provide local leadership, enthusiasm, and a sense of duty. CONCLUSIONS: By supporting and facilitating local veteran leaders and their community partners in increasing suicide prevention knowledge, public awareness, and resources, we propose that TWV offers an acceptable and feasible approach that builds on the strengths of rural communities. Systematic evaluation is warranted.

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Suicide is a significant public health concern for veterans residing in rural communities. Although various initiatives have been implemented to prevent suicide among veterans, efforts specific to rural veterans remain limited. To aid such efforts, we examined stigma as a potential barrier to community readiness in the implementation of a community-based suicide prevention program for rural veterans. In this qualitative study, community readiness interviews were conducted with 13 participants in a rural community. Themes included lack of awareness regarding veteran suicide, rare discussions of veteran suicide, and suicide-related stigma within the community. Results suggest that prioritizing destigmatization may be particularly important to implementing community-based suicide prevention programming in rural communities. In particular, addressing community misconceptions regarding veteran suicide, while increasing knowledge of the extent to which veteran suicide occurs locally may facilitate increased awareness and thus community readiness to prevent suicide among rural veterans.

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Suicide rates are higher in rural communities than in their urban counterparts. Of particular concern are veterans residing in rural communities, who have a 20% higher risk of dying by suicide than veterans who live in urban areas. The objective of this manuscript is to assess the availability of evidence-based and promising practices to support a community-based suicide prevention effort for rural veterans. We compiled a compendium of evidence-based and promising practices-the "menu of options"-with resources across 4 levels: increasing access to crisis services, enhancing primary care suicide prevention, training community members, and raising public awareness. We compiled resources from multiple sources, then reviewed and rated each one to arrive at consensus on the final selections. The final menu includes 70 resources. However, only 20 are tailored for veterans, only one for rural communities, and none for rural veterans. More research is needed to identify effective strategies and develop rural-tailored resources for preventing suicide among this unique and often underserved population. The menu of options represents a first step toward developing an approach to rural veteran-suicide prevention that aligns with evidence-based practice, theory, and a public health model for suicide prevention. (PsycINFO Database Record

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The stigma associated with mental illness or addiction is significantly and positively related to psychiatric symptoms. According to Modified Labeling Theory, several processes should mediate this relationship, including rejection experiences, stigma management (secrecy coping), and social support. In the first comprehensive test of this theory, we examined a serial mediation model on three waves of data from 138 adults receiving outpatient behavioral health treatment. Participants were recruited from outpatient behavioral health clinics in a large northeastern city in the United States and completed interviews that assessed stigma, rejection experiences, stigma management, social support, and psychiatric symptoms. There was a direct effect between stigma and psychiatric symptoms and an indirect effect in which perceived rejection, secrecy coping and social support sequentially and longitudinally intervened in the stigma and psychiatric symptom relationship. Higher perceptions of stigma predicted more rejection experiences, which marginally increased secrecy coping and decreased social support. In turn, decreased social support increased psychiatric symptoms. We provide support for Modified Labeling Theory and the clinical utility of specific mediators in the relationship between stigma and psychiatric symptoms among adults in behavioral health treatment living in urban settings.

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INTRODUCTION: Persistent stigma, lack of knowledge about mental health, and negative attitudes toward treatment are among the most significant barriers to military service members and veterans seeking behavioral health care. With the high rates of untreated behavioral health needs among service members and veterans, identifying effective programs for reducing barriers to care is a national priority. This study adapted Mental Health First Aid (MHFA), an evidence-based program for increasing mental health knowledge, decreasing stigma, and increasing laypeople's confidence in helping and frequency of referring people in need, for military and veteran populations and pilot tested the adapted training program with 4 Army National Guard armories. MATERIALS AND METHODS: A total of 176 community first responders (CFRs) participated in a comparative outcomes study, with 69 receiving the training and 107 participating in the control group. CFRs were individuals in natural positions within the Armory or home communities of Guard members to identify and help service members in mental health crisis. Surveys assessing confidence in helping, attitudes toward help seeking, knowledge of resources, use of MHFA practices, and stigma were completed before the training, immediately post-training, at 4 months post-training, and at 8 months post-training. Analyses included repeated measures analysis of variances on data from CFRs who received the training and mixed between-within subjects analysis of variances comparing the intervention and control group longitudinally at three time points. Institutional review board approval for this study was received from Montana State University and the U.S. Army Medical Department, Medical Research and Materiel Command, Human Research Protection Office. RESULTS: Significant and meaningful improvements in confidence (p < 0.05, η2 = 0.49), knowledge (p < 0.05, η2 = 0.39), behaviors (p < 0.05, η2 = 0.27), and stigma (p < 0.05, η2 = 0.16) were observed among trainees. When compared to a control group, statistically meaningful differences in change over time were observed for knowledge (η2 = 0.03), attitudes (η2 = 0.02), confidence (η2 = 0.06), and stigma (η2 = 0.02), with a significant and meaningful difference observed for practice behaviors (p < 0.05, η2 = 0.07). CONCLUSIONS: Results from the comparative outcomes pilot study of military and veterans MHFA indicate that the intervention is acceptable and feasible to implement in National Guard Armories and among non-Guard community-based first responders. There was a significant intervention effect detected for the likelihood that a CFR would use appropriate engagement, support, and referral practices when identifying someone in need of mental health support. In addition, there were positive growth trends in the data for improvements in confidence, knowledge of mental health resources, attitudes toward help seeking, and stigma, which indicate that with a larger number of participants and armories we would expect to see significant intervention effects. Study weaknesses included insufficient power and demographic data for more robust analyses of intervention effects. A larger randomized controlled trial is recommended for better establishing efficacy; however, these results indicate that Military and Veterans MHFA is a promising intervention for reducing critical barriers to care.

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