The Department of Veterans Affairs (VA) is 

committed to providing care for Veterans with 

post-traumatic stress disorder (PTSD) and to 

preventing suicide among Veterans. VA has 

undertaken extensive efforts in the last five 

years to implement enhancements to mental 

health care, many focused on PTSD care and 

on suicide prevention. VA is committed to 

improving and enhancing access to care and 

the quality of care delivered, and to expanding 

knowledge through research. 

PTSD Treatment

VA develops Clinical Practice Guidelines 

(CPGs) in conjunction with the Department 

of Defense (DoD) on a wide array of health 

care issues, including several mental health 

diagnoses and problems. The CPGs are developed in a thoughtful, data-driven process, 

resulting in documents that guide assessment 

and disease management, and, when possible, 

prevention of disorders. The most recently 

revised CPG for PTSD was published in 2010, 

as an update from the original 2004 CPG for 

PTSD. 

The role of CPGs is to guide clinical decisionmaking, not to dictate clinical care. VA 

emphasizes that patient preferences must be 

addressed, with the patient being a full collaborator in treatment planning and decisions. 

As potentially effective treatment options 

increase, Veterans can take an active role in 

deciding how each option fits with their goals, 

strengths, and challenges. 

VA must develop providers who can deliver 

with clinical skill and fidelity the treatments 

shown most likely to be effective. To support 

this, the VA Office of Mental Health Services 

(OMHS) has taken a lead role in identifying the training needs of VA’s mental health 

work force and developing programs to targe

those needs. VA has trained thousands of 

mental health clinicians to provide the psychotherapies rated most effective for PTSD 

in both the CPG and in an independent 2007 

report by the Institute of Medicine: Cognitive 

Processing Therapy and Prolonged Exposure 

Therapy. VA’s National Center for PTSD 

(NCPTSD) also delivers training for PTSD 

treatment providers through a national mentoring program that shares best practices in 

PTSD care across Veterans Integrated Service 

Networks (VISNs) and VA medical facilities. 

The PTSD CPG must continue to evolve as 

knowledge progresses through research. For 

example, many Veterans want their family 

members more involved in PTSD treatment. 

While VA has expanded authority to allow 

family involvement in PTSD treatment, little 

empirical evidence exists to guide how clinicians may effectively adapt to these preferences. Additionally, the value of the PTSD 

CPG would be greatly increased by an evidence base to guide adjustments to treatment 

when clients present with common comorbid

ities, such as pain, insomnia, anger, substance 

use disorders, or traumatic brain injury. 

FORUM

Translating research into quality health care for Veterans

Commentary

PTSD Treatment and Suicide Prevention: 

Clinical Practice Guidelines and Steps 

Toward Further Knowledge

Antonette M. Zeiss, Ph.D. and Janet Kemp, R.N., Ph.D., Office of Mental Health Services,

U. S. Department of Veterans Affairs Central Office, Washington, D.C.

 May 2012

Contents

Director’s Letter 2

PTSD Treatment and Suicide 

Prevention: VA Research 

Contributions and Priorities 3

Suicidal Behavior among Those 

with TBI and PTSD 4

Gender and PTSD 5

The Role of Primary Care in 

Addressing Suicide Risk 6 

Compensation and Pension 

Examination for PTSD 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, in 

conjunction with AcademyHealth. 
Suicide Prevention

Suicide prevention is integral to VA’s mental

health efforts. Currently, a suicide prevention

CPG is under development with the DoD, and

should provide invaluable clinical guidance. The

2008 recommendations of a Blue Ribbon panel

of suicidology experts have contributed to development of these guidelines. The foundation

for effective suicide prevention is good mental

health care—for PTSD and for all diagnosable

mental illness and other emotional challenges.

At the core of VA’s program is VA’s Crisis

Line, a 24/7 phone line run in collaboration

with SAMHSA’s Lifeline, established in 2007. 

Veterans, or those concerned about a Veteran,

can call 1-800-273-8255 and then press 1 to be

connected to a VA mental health professional

trained to work with those in crisis or who may

be potentially suicidal. Since its founding, the

Crisis Line has received over 500,000 calls and

initiated over 19,000 rescues. Such rescues involve dispatching emergency personnel to the

site of an imminent suicide, securing the person

and any others in the area, and ensuring the person receives urgent care.

One invaluable feature of VA’s Crisis Line

is that staff can link to the Veteran’s Electronic Health Record, if the Veteran is willin

to share his or her name and social security

number. This feature allows the Crisis Line

responder to link the caller to mental health

providers who have seen the Veteran previously and to get immediate help. In addition

VA employs Suicide Prevention Coordinato

(SPCs) at every facility and large clinic to ar

range immediate local response. The SPCs

follow up with Veterans to ensure they con

tinue care and receive the support they need

and to develop safety plans.

Building on the success of the call line, VA

has opened a written Chat Service at www.

veterancrisisline.net and a texting service, at

838255, both of which connect those seekin

care directly to mental health professionals

who staff Crisis Line calls. These services e

pecially appeal to younger Veterans, for wh

these communication options are familiar a

preferred.

Numerous opportunities for research remai

Many relationships between suicidality and 

diagnosed mental illness are known, but the

is much to learn, particularly about the sam

issues of chronicity and comorbidity that ar

central for PTSD care. In addition, one of t

most challenging issues is that a large propo

tion of suicides occur in those without any

known mental illness. Often such suicides

occur after a primary care visit, and without

any obvious warning signs that the individu

is at risk for suicide. Research focused on th

underlying issues for such patients, how to

identify them, and what care could best pre

vent suicide in this group would be invaluab

for VA and for the nation.

References

1. Batten, S. V. et al. “Veteran Interest in Family

Involvement in PTSD Treatment,”

Psychological Services 2009; 6:184-9. 

2. Institute of Medicine (2007). Treatment of Post-trauma

Stress Disorder: An Assessment of the Evidence. Washing

DC: The National Academies Press.

3. VA/DoD Clinical Practice Guideline (2010). Manag

ment of Post-Traumatic Stress, Version 2.0. Washington

DC: Department of Veterans Affairs and Departme

of Defense.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter: BIG3– Big Data, Big Ideas,

Big Research

On March 29, 2012 the White House Office of Science and

Technology Policy (OSTP) announced the federal government’s

Big Data Research and Development Initiative. Included in the

initiative are the goals of advancing core technologies for analyzing and sharing huge quantities of data, harnessing Big Data

knowledge and technologies to accelerate scientific discovery, using Big Data to

transform teaching and learning, fostering public-private Big Data partnerships,

and developing a Big Data workforce.

VA investigators are at the forefront of Big Data research, since they have access

to vast, detailed Big Data health information (e.g., 2 billion clinical notes, 5 billion

laboratory tests), an expanding cadre of Big Data investigators, established nonVA Big Data relationships, a clear mission to apply Big Data methods to improve

Veteran health, and strong programmatic support for the Big Data concept. VA

investigators are active participants in the Big Data initiative through ORD’s support of the CHIR, ProWatch, VINCI, OMOP, iEHR, GenISIS, and MVP programs

(download http://www.whitehouse.gov/sites/default/files/microsites/ostp/big_

data_press_release_final_2.pdf for details).

Important Big Data issues for VA investigators to consider addressing are: using

NLP (natural language processing) to extract useful clinical and research information from the VA’s vast text data resources, transforming information into a format

that can be readily applied by providers and patients at points of care, expanding

the application of Big Data to improve personalized medicine, and using Big Data

concepts to predict adverse and beneficial health outcomes.

Regardless of your current research interests, your careers will be impacted by the

Big Data initiative, and the concepts and projects it will spawn. I encourage you

to watch the two hour scientific discussion of the rationale and vision for the initiative, posted on the National Science Foundation’s website. Please visit http://

www.nsf.gov/news/news_videos.jsp?cntn_id=123607&media_id=72174&org=NSF.

Seth Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service May 2012
VA Office of Research & Development, Health Services Research & Development Service May 2012

In this issue’s commentary article, Dr. Zeiss 

discusses expansion of VA Mental Health 

Services and post-traumatic stress disorder 

(PTSD) treatment initiatives in the VA; she 

points out the importance of Clinical Practice 

Guidelines as a means for improving clinical 

care. She further discusses how the VA has 

not only published and updated PTSD treatment guidelines in conjunction with the DoD, 

but has also taken impressive, practical steps 

to ensure that guideline recommendations can 

be implemented. 

Following the growing evidence for psychotherapies for PTSD, the VA leadership 

chose not to simply rely on dissemination of 

guidelines to make changes in VA clinician 

practices—but proceeded with a massive and 

unprecedented effort to “train up” and support VA mental health clinicians in providing 

these established PTSD psychotherapies.1

Starting in 2005-2006, the VA increased its 

mental health workforce capacity—hiring 

additional clinicians, beginning ongoing, systematic training of these clinicians, and conducting systems reorganization to support the 

provision of evidence-based psychotherapies.

As of May 2010, over 2,700 VA mental health 

clinicians had received training in either Prolonged Exposure (PE) or Cognitive Processing 

Therapy (CPT) for PTSD, through multi-day, 

in-person trainings, and weekly systematic consultation and small group supervision. VA has 

also placed local evidence-based psychotherapy 

coordinators at each medical facility to champion implementation of these treatments and 

to work with site leadership to organize clinic 

flow for improved treatment implementation. 

Importantly, an implementation model that established structures and processes to maintain 

the use of these therapies after the initial training period was developed. 

This ambitious effort raises new questions 

regarding systems change and maintenance. 

Both CPT and PE require weekly delivery of 

treatment sessions for multiple weeks—presenting a challenge in busy VA clinics facing 

rising numbers of returning Veterans from 

the OEF/OIF conflicts. Engaging Veteran 

patients in completing treatment is also a challenge, with HSR&D researchers recently reporting that only a small minority (9.5 percent) 

of OEF/OIF Veterans with new PTSD diagnoses attended nine or more VA mental health 

sessions within 15 weeks in the first year following their diagnosis.2 Moving to decentralized training and maintaining clinician expertise 

over time presents additional challenges. VA 

implementation scientists have the opportunity 

to substantially contribute in these areas, studying factors that affect the maintenance and improvement of the system capacities to provide 

these complex psychotherapies to increasing 

numbers of Veterans with need.

The commentary article’s co-author, Dr. 

Kemp, outlines a second area of considerable 

effort on the part of VA Office of Mental 

Health Services—suicide prevention. As she 

discusses, suicide prevention is integral to the 

VA mental health services efforts, and enormous resources have been devoted to decreasing suicide among VA Health System users 

and among Veterans in the community. These 

efforts have included increasing overall mental 

health capacity and quality, such as the efforts 

described above to improve capacity and care 

for PTSD. Efforts have also included suicidespecific interventions, such as the Veteran Suicide Hotline and placing Suicide Prevention 

Coordinators (SPCs) and Care Managers at 

each VA facility. The VA Crisis Line is one of 

the few crisis lines that can, with the Veteran’s 

permission, integrate the call into the Veteran’s medical record and facilitate the connection of callers to VA care through outreach by 

Suicide Prevention Coordinators.

However, despite these efforts, the evidence 

base for suicide prevention interventions remains limited and the goal of rapidly reducing 

the suicide rate has remained elusive—both 

within the VA and nationwide. 

VA HSR&D researchers have conducted 

a synthesis of the evidence-based literature 

on suicide prevention, finding that although 

some approaches—such as multi-component 

intervention in military populations—are 

promising, the quality of evidence for this 

and most other suicide prevention strategies 

is low, meaning that further research is likely 

to have an important impact on or change 

the estimate of the effect.3

 Unfortunately, 

insufficient studies exist of suicide prevention programs specifically in Veterans from 

which to draw conclusions, and no studies 

exist that assessed the specific effectiveness of 

hotlines, outreach programs, peer counseling, 

treatment coordination programs, and other 

important care initiatives on suicide rates. 

Thus, there is a clear need for further randomized controlled trials and high-quality 

observational studies to advance knowledge 

in the area of suicide prevention. HSR&D 

research is well-positioned to contribute in 

this high priority area for the VA, working 

in tandem with the Office of Mental Health 

Services on evaluating the impact of current 

efforts to reduce suicide risks and on implementing the strategies that are most effective. 

References

1. Karlin, B.E. et al. “Dissemination of Evidence-based 

Psychological Treatments for Posttraumatic Stress 

Disorder in the Veterans Health Administration,” 

Journal of Traumatic Stress 2010; 23(6):663-73. 

2. Seal, K.H. et al. “VA Mental Health Services 

Utilization in Iraq and Afghanistan Veterans in the 

First Year of Receiving New Mental Health Diagnoses,” 

Journal of Traumatic Stress 2010; 23(1):5-16.

3. Bagley, S.C. et al. “A Systematic Review of Suicide 

Prevention Programs for Military or Veterans,” 

Journal of Suicide and Life Threatening Behavior 2010; 

40(3):257-65.

Response to Commentary

PTSD Treatment and Suicide Prevention: 

VA Research Contributions and Priorities

Marcia Valenstein, M.D., Center for Clinical Management Research, 

Ann Arbor, Michigan

FORUM — Translating research into quality health care for Veterans 3
Like individuals from previous Veteran cohorts, military personnel serving in Iraq and 

Afghanistan are being exposed to physical 

and psychological traumas that place them at 

risk for traumatic brain injury (TBI) and/or 

post-traumatic stress disorder (PTSD). Both 

of these conditions are associated with negative outcomes. Recent research suggests that 

Veterans with TBI and/or PTSD may be at 

risk for self-directed violence (SDV) such as 

suicide attempts and death by suicide. 

Death by Suicide among Those 

with TBI1

Although previous studies supported the 

relationship between history of TBI and suicide in the general population, no research 

had been conducted to explore TBI as a risk 

factor for SDV among those seeking care at 

Veterans Health Administration (VHA) facilities. Using data from VHA electronic medical 

records and the National Death Index (NDI), 

we examined the relationship between history 

of TBI and death by suicide among individuals who had sought VHA care between 2001 

and 2006. Analyses included all individuals 

with a history of TBI (n = 49,626) plus a 5 

percent random sample of patients without 

TBI (n = 389,053). VHA users with a history of TBI were 1.55 times more likely to 

die by suicide than those without a history 

of TBI. The increased risk was not explained 

by the presence of psychiatric disorders or 

demographic factors. This finding suggests 

that history of TBI had an independent influence; thereby highlighting the possibility that 

injury-specific factors such as cognitive dysfunction or TBI-related psychosocial stressors (e.g., loss of employment, marital discord) 

may contribute to risk. 

Moreover, among individuals whose data 

were included in the study, significant differences were identified in the rate of all 

psychiatric diagnoses (e.g., PTSD) between 

those who died by suicide and those who did 

not. In addition, the rate of PTSD was significantly greater (p< .0001) among those with 

TBI who died by suicide (21.9 percent) versus 

those with TBI who did not die by suicide 

(9.81 percent). This suggests that a diagnosis 

of PTSD may increase risk for death by suicide among those with a history of TBI. 

PTSD and Suicide Attempt 

History among Those with and 

without TBI2

We also looked at the relationship between 

PTSD and suicide attempt history in those 

with and without TBI who were using VHA 

mental health services. Electronic medical 

records were used to identify history of TBI, 

PTSD, and/or suicide attempt. Findings suggested that a history of PTSD was associated 

with suicidal behavior among those with and 

without a history of TBI. Specifically, the 

odds of a suicide attempt for those with a history of PTSD were 2.8 times that of the odds 

for those without PTSD. Similarly, for those 

with both PTSD and TBI the likelihood of a 

suicide attempt was 3.3 times greater than for 

those with a TBI alone. 

Recommendations for Clinical 

Practice

Findings from the presented studies suggest 

that continued research is needed to increase 

understanding regarding the complex relationship between TBI, PTSD, and suicidal 

behaviors. It is likely that factors associated 

with increased risk (e.g., history of risky behavior, executive dysfunction) vary by TBI 

severity (i.e., mild, moderate, severe) and are 

exacerbated by PTSD symptoms. Mild TBI 

versus moderate/severe TBI are distinct conditions. Knowledge regarding differences associated with TBI severity will allow clinician

to appropriately conceptualize the degree to 

which the injury sustained would be expected 

to impact functioning. Regardless of injury 

severity, the focus of treatment should be rehabilitation/recovery oriented.

Based on the presented results, sufficient 

data exist to: 1) support screening for TBI 

among those with PTSD; 2) support screening for PTSD among those with TBI; and 3) 

consider PTSD and/or TBI as potential risk 

factors for suicidal behavior. For more recent 

Veterans, TBI screening procedures are in 

place; however, further work is required to 

identify psychometrically sound screening 

strategies for Veterans from previous cohorts

If a history of TBI is identified, clinicians 

are encouraged to evaluate for injury-related 

factors that may be contributing to increased 

risk. Those with moderate to severe injury 

often face challenges both at home and at 

work. Job loss and divorce are common. In 

addition, organic injury may contribute to increased impulsivity and aggression, and poor 

decisionmaking—all risk factors for suicidal 

behavior. Development of safety and treatment plans with these contributors in mind is 

recommended. For educational materials and 

information about current VISN 19 Mental 

Illness Research, Education and Clinical 

Center (MIRECC) research regarding TBI, 

PTSD, and suicide please visit www.mirecc.

va.gov/visn19/.

References

1. Brenner, L.A. et al. “Suicide and Traumatic Brain Injury among Individuals Seeking VHA Services,” Journa

Head Trauma Rehabilitation 2011; 26(4):257-64.

2. Brenner, L.A. et al. “Post-traumatic Stress Disorder, 

Traumatic Brain Injury, and Suicide Attempt History 

among Veterans Receiving Mental Health Services,” 

Suicide and Life-Threatening Behavior 2011; 41(4):416-23. 

FORUM Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service May 2012

Research Highlight

Suicidal Behavior among Those with 

TBI and PTSD

Lisa Brenner, Ph.D., ABPP, Director, VISN 19 MIRECC, Denver, Colorado
VA Office of Research & Development, Health Services Research & Development Service May 2012

FORUM Translating research into quality health care for Veterans 5

Reviews and meta-analyses of the post-traumatic stress disorder (PTSD) literature consistently find that women experience PTSD 

at rates approximately twice that of men. In 

the general population, the prevalence of 

PTSD is about 5.2 percent among women 

and 1.8 percent among men. This gender 

difference is largely a function of the type of 

traumas women experience and their social 

roles. Women are disproportionately more 

likely than men to be exposed to traumatic 

events such as intimate partner violence and 

sexual abuse, which are often in the context 

of intimate interpersonal relationships, serial in nature, may increase in severity over 

time, and pose a high conditional risk for 

PTSD. Research with survivors of natural 

disaster, a seemingly gender neutral event, 

has found that women in cultures with more 

traditional gender roles, or women in social 

roles of wife and mother, are more likely to 

experience PTSD. 

Several important gender issues in PTSD 

among Veterans have been elucidated by 

recent studies of the conceptualization of 

military and deployment related stressors 

and social contexts. Initial estimates of combat-related PTSD among Vietnam-era Veterans found significantly higher rates among 

men (15.2 percent) as compared to women 

(8.5 percent), and these gender differences 

were largely due to higher rates of combat 

exposure among men. Increasing focus on 

women’s experiences in Vietnam and subsequent conflicts found experiences such 

as exposure to death and dying and other 

elements of the aftermath of battle, difficult 

living and working conditions, and experiences of sexual assault and harassment were 

also associated with war-related PTSD. 

Since Vietnam, the numbers of women in 

the military have substantially increased, and 

their roles have expanded considerably. Conceptualizations of combat exposure have also 

been expanded, and research has demonstrated 

that this broader range of stressor experiences is 

essential for understanding PTSD in both men 

and women. There is still a higher prevalence of 

PTSD among male OEF/OIF/OND Veterans 

in VHA as compared to women OEF/OIF/

OND Veterans, though these differences are 

moderate (22 percent as compared to 17 percent). PTSD symptoms appear to map closely 

to the degree of exposure to combat stressors, 

with men and women demonstrating similar 

levels of resilience.1

 Social factors, such as concerns about disruptions in family and social 

relationships and post-deployment social support, show a stronger impact on women’s postdeployment adjustment as compared to men. 

Similar to civilian studies, these data highlight 

the importance of social factors in women’s 

PTSD found in the Veteran population.

As VHA moves toward Veteran-centered care, 

our challenge is to include a focus on gender 

in PTSD research, and translate these findings 

into policies and interventions that will help 

promote access to and engagement with treatment for PTSD. For example, there is strong 

anecdotal evidence that many women Veterans prefer female mental health providers or 

gender-specific treatment settings for PTSDrelated care. We need more information on how 

to quantify and address both gender-specific 

preferences and trauma-specific treatment preferences for the growing numbers of women 

seeking care for combat-related PTSD. Similarly, there is little evidence regarding genderspecific treatment issues and preferences among 

men seeking care for PTSD-related to military 

sexual trauma (MST). 

Families and social networks can help promote access to care among Veterans with 

PTSD.2

 As VHA mental health services 

become more inclusive of family members, 

research that addresses the importance of 

family and social factors for women’s PTSD 

can help guide implementation of these expanded services. 

Finally, considerations of gender and PTSD 

need to look beyond the diagnosis to broader 

domains of health and social functioning. 

Emerging research suggests that women 

OEF/OIF/OND Veterans bear an especially 

heavy burden of medical comorbidity as 

compared to men. Research examining gender differences and gender-specific interventions in the detection and treatment of PTSD 

in primary care, and gender specific investigations of the quality of care for Veterans with 

comorbid conditions are especially important 

in the reproductive-aged OEF/OIF cohort. 

Recent research has also identified PTSD, 

and particularly MST, as risk factors for 

homelessness among Veteran women, which 

is an increasing problem among the growing number of female Veterans.3

 Gender 

specific research with homeless and at risk 

populations should examine interventions 

to address trauma and PTSD, logistical and 

clinical issues for women with children, and 

provision of specialized services in programs 

that see few women. 

While there is still much to learn in relation 

to gender and PTSD, a number of ongoing HSR&D and VA projects are examining 

these important issues to ensure that both 

male and female Veterans continue to have 

access to quality PTSD care.

References

1. Vogt, D. et al. “Gender Differences in Combat-related Stressors and their Association with Postdeployment Mental Health in a Nationally Representative 

Sample of U.S. OEF/OIF Veterans,” Journal of Abnormal Psychology 2011; 120(4):797-806.

2. Sayer, N.A. et al. “A Qualitative Study of Determinants of PTSD Treatment Initiation in Veterans,” 

Psychiatry Fall 2009; 72(3):238-55.

3. Balshem, H. et al. “A Critical Review of the 

Literature Regarding Homelessness among Veterans,” 

VA-ESP Project #05-225; 2011.

Research Highlight

Gender and PTSD

Rachel Kimerling, Ph.D. and Jessica A. Turchik, Ph.D., National Center for PTSD & 

Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, California
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service May 2012

It has been estimated that up to 18 Veterans die each day by suicide. The subgroup 

of Veterans who receive care within the 

VA health care system are at greater risk 

for suicide compared to non-Veterans; the 

rate of suicide within this subgroup has 

decreased only slightly in recent years.1 Welldocumented risk factors for suicide include 

previous suicide behaviors, psychiatric and 

general medical conditions, male sex, poor 

psychosocial support, access to means for 

suicide (especially firearms), losses, and recent psychiatric hospitalization. 

VA Suicide Prevention Activities

The VA has developed a comprehensive 

strategy in an effort to reduce the incidence 

of suicide. Specifically, the VA has implemented screening for conditions commonly 

associated with suicide behaviors; developed 

national performance measures and tools to 

facilitate assessment of suicide risk; and created a “Veterans Suicide Prevention Hotline” 

that provides ready access for Veterans and 

their families to seek and receive help. The 

VA has also implemented training programs 

for VA staff and created the Suicide Prevention Coordination Program, which funds suicide prevention coordinators at VA facilities 

and facilitates monitoring and safety plan development for high risk patients. In addition, 

through the Primary Care-Mental Health 

Integration and Translating Initiatives for 

Depression into Effective Solutions (TIDES) 

initiatives, the VA has implemented colocated and collaborative mental health care 

approaches designed to support primary-care 

based Patient Aligned Care Teams (PACTs), 

and to enhance primary care patient access to 

high quality mental health care.

Primary Care Interactions with 

Veterans at Risk

Primary care clinicians have a critical role to 

play in addressing suicide risk of Veterans by 

detecting and treating important mental and 

general medical conditions, and being prepared to identify and respond to opportunities 

to intervene when Veterans are at high risk. 

Prior research indicates that a considerable 

proportion of individuals who die by suicide 

make contact with health care clinicians prior 

to death. According to multiple studies, half 

of individuals make contact with primary 

care providers in the month prior to death, 

while a much smaller proportion make contact with mental health care clinicians during 

that month. During these contacts, it is not 

clear whether patients are specifically seeking help for emotional distress versus seeking 

care for general medical conditions, although 

several recent studies suggest that emotional 

issues are frequently not addressed at these 

last visits.2,3 In a study using a small sample of 

Veterans from Oregon who subsequently died 

by suicide, we found that less than one-third 

of the patients acknowledged suicidal ideation 

even when they were asked about it during last 

visits with primary care clinicians.2

Mental disorders are common among Veterans treated by primary care clinicians, and 

these disorders, as well as general medical 

conditions, increase risk for suicide behaviors. 

Key conditions for primary care clinicians to 

detect and treat include depression, anxiety, 

and substance use disorders. These conditions have been well-documented to increase 

risk for suicide behaviors, and many Veterans 

who receive treatment for these disorders 

receive it only in primary care settings. Less 

clear is the relationship between PTSD and 

suicide—while some studies have shown 

PTSD increases risk for suicide, others have 

found weaker associations between PTSD 

and suicide. Traumatic brain injury, which is 

often comorbid with PTSD, may also be an 

important risk factor for suicide. However, 

to date there are few data available to support this relationship; studies examining this 

question are in progress. Finally, other studies 

have shown that chronic pain frequency and 

intensity may be associated with a two-fold 

increase in rates of suicide behaviors. Importantly, insomnia and anxiety may further increase risk for suicide among individuals who 

have pain or other comorbid conditions.

Further innovation and research is needed to 

optimize the role of PACTs in suicide prevention. We need to further develop and implement training programs that enhance PACT 

members’ ability to: a) address and treat 

depression, anxiety, substance use disorders, 

chronic pain, and insomnia; b) recognize and 

respond to suicidal ideation as well as other 

warning signs of patient distress; and c) use 

motivational interviewing techniques to help 

high-needs patients transition to specialists 

when specialty care is indicated. At a systems 

level, it is important that the VA continue 

to support development and testing of sustainable collaborative approaches, including 

decision support and care management for 

conditions that increase the risk for suicide behaviors. Development of additional processes 

that facilitate communication and coordination among PACTs, mental health clinicians, 

and Veterans as Veterans make transitions 

between care settings is also needed.

References

1. Blow, F.C. et al. “Suicide Mortality Among Patients 

Treated by the Veterans Health Administration from 

2000 to 2007,” American Journal of Public Health 2012; 

102(S1):S98-S104.

2. Denneson, L.M. et al. “Suicide Risk Assessment and 

Content of VA Health Care Contacts Before Suicide 

Completion by Veterans in Oregon,” Psychiatric Services 

Journal 2011; 61(12):1192-7.

3. Smith, E.G. et al. “Treatment of Veterans with Depression who Died by Suicide: Timing and Quality of 

Care at last Veterans Health Administration Visit,” 

Journal of Clinical Psychiatry 2011; 72(5):622-9.

Research Highlight

The Role of Primary Care in Addressing 

Suicide Risk

Steven K. Dobscha M.D., Center for the Study of Chronic Comorbid Mental and 

Physical Disorders, Portland VA Medical Center, Portland, Oregon
VA Office of Research & Development, Health Services Research & Development Service May 2012

FORUM — Translating research into quality health care for Veterans 7

The approval of a claim for service-connected

post-traumatic stress disorder (PTSD) results in

priority access to VA health care and financial 

compensation. Veterans currently receive over

$4 billion dollars annually in compensation

for PTSD. The number of Veterans in 2010

with service-connected PTSD was 386,882, a

222 percent increase from 1999. The trend for

rapidly rising costs of service-connected PTSD

prompted an investigative report in 2005 by the

VA Office of Inspector General. The report 

found that compensation for PTSD out-paced

all other conditions and that wide regional variations exist in the rates of service-connected

PTSD. The report attributed this wide variation

across the network of VA medical centers in

part to variation in compensation and pension

(C&P) examinations. 

In studies on PTSD, the Clinician-Administered

PTSD Scale (CAPS) has been used in hundreds

of research protocols, resulting in CAPS becoming the gold standard for diagnosis.1

 Standardized

administration is accomplished through carefully

worded prompts and scale anchors with explicit

behavioral referents. Initial prompt questions

target each core symptom of PTSD, and followup prompts help clinicians clarify the linkage between symptom and trauma. Similarly, the World

Health Organization Disability Assessment 

Schedule II (WHODAS-II) is a standardized 

interview of functional impairment.2Given that

these evidence-based, standardized, diagnostic

tools are used routinely to enhance the validity of

research studies on PTSD, the incorporation of

these diagnostic methods may likewise produce

greater accountability and consistency in the disability examination for PTSD.

A surprising lack of rigorous studies exists on

evidence-based, standardized assessment for

disability. We addressed this evidence gap by

conducting a cluster randomized controlled

trial in a sample of Veterans seeking PTSD

disability compensation from the VA—the

Enhancing Equitable and Effective PTSD

(E3-PTSD) Disability Assessment Study.

The trial compared typical clinical interviews

with standardized assessments that incorporated the CAPS for PTSD diagnosis and the

WHODAS-II for functional impairment. We 

expected that Veterans in the standardized

assessment condition would receive more

complete and accurate assessment of the

DSM-IV-TR diagnostic components of PTSD 

and related functional impairment compared

with Veterans in the usual practice condition.

Our study found that administering a standardized disability assessment resulted in more

complete assessment of functional impairment

and diagnostic coverage of PTSD. Standardized assessment elicited an increase in relevant

information for each of the core diagnostic

criteria, and nearly eliminated variation between

examiners and medical centers. Furthermore,

the study found that standardized assessment

substantially diminished the uncertainty in diagnosis, and increased concordance of diagnosis

with the NC-PTSD experts.

The CAPS added 15-20 minutes to the assessment process. A majority of the clinicians

found the CAPS useful and would support

making it a routine part of the assessment

(56 percent support/25 percent oppose/19

percent ambivalent). The vast majority of

clinicians did not find the WHODAS useful 

and would oppose making it a routine requirement. Clinicians’ primary objection was that

the WHODAS was not specific enough for 

functional impairments attributable to PTSD.

Reflections and Looking Forward

In a survey of VA clinical examiners, we

found that the CAPS or other structured interview methods are rarely used in Veteran

C&P disability assessment.3 The more routine

and common practice is the open-ended, unstructured clinical interview concurrent with

the use of a report writing template. The findings of our study indicate that evidence-based

standardized disability assessment for PTSD

would enhance the clinician’s determination

of a PTSD diagnosis and functional impairment, and make the disability examination

process more reliable and valid.

Research Highlight

Compensation and Pension

Examination for PTSD

Ted Speroff, Ph.D., VA Tennessee Valley Healthcare System GRECC and Health

Services Research, Nashville, Tennessee and Patricia Sinnott PT Ph.D., M.P.H.,

Health Economics Resource Center, Palo Alto, California

Yano Receives 2012 Under Secretary’s Award for Outstanding Achievement in Health Services Research

Elizabeth Martin Yano, Ph.D., M.S.P.H., will receive this year’s Under Secretary’s

Award for Outstanding Achievement in Health Services Research. The Award recognizes a VA researcher whose work has met three key criteria: improved our understanding of factors that affect the health of Veterans and improved the quality

of their care, contributed to the future of VA health services research by inspiring

and training the next generation of investigators, and enhanced the visibility of VA research.

Dr. Yano’s research focuses on organizational influences on quality and the implementation

of evidence-based practice. She is working to inform VA’s efforts to implement and evaluate

VA Patient-Aligned Care Teams (PACTs). She also serves as principal investigator for the

National VA Women’s Health Research Consortium and Practice-Based Research Network,

which provides infrastructure for advancing VA research to improve the organization, quality,

and impacts of the delivery of VA health care services to meet women Veterans’ needs.

Dr. Yano serves as co-Director of HSR&D’s Center for the Study of Healthcare Provider

Behavior in Sepulveda, CA, and has been a part of the Center since its inception.

Dr. Yano is a scholar, mentor, and prolific author, generating more than 100 peer-reviewed publications. The Under Secretary’s Award will be presented to Dr. Yano at the

HSR&D/QUERI National Meeting in July. Continued on page 8
Peter L. Almenoff, M.D., FCCP, 

Office of Informatics and 

Analytics, VA Central Office, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

QUERI Director,

VA Central Office, 

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H., 

Office of Informatics and 

Analytics, VA Central Office, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach, 

Long Beach, CA 

Richard Owen, M.D., Director, 

VA HSR&D Center of 

Excellence, Little Rock, AR 

Alan S. Perry, M.P.A., M.H.A., 

FACHE, Retired, 

VA Central California Health Care 

System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of 

Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

FORUM

Translating research into quality health care for Veterans

Center for Information Dissemination and Education Resources 

VA Boston Healthcare System (152C) 

150 South Huntington Avenue, Boston, MA 02130-4893

Organization

U.S. Postage

PAID

Permit No. 3999

Washington, DC

The E3-PTSD study was formulated to 

meet the need of the Veterans Benefits 

Administration and the Veterans Healthcare Administration to inquire about variations in the C&P examination process. We 

encountered challenges in navigating the 

two worlds of research and operations, 

and in overcoming the hurdles of multiple 

Institutional Review Boards. We also faced 

difficulty in embedding a study within pure 

facility operations of C&P and the realities 

of completing examinations within a 30-day 

window of time. During the course of the 

study, we had to adjust to volatile events resulting in suspension and then surveillance 

of PTSD research, and contend with policy 

changes on conceding PTSD stressors. 

These challenges resulted in slowing study 

enrollment and then flooding VHA with 

PTSD examinations. As HSR&D moves toward more partner service-directed research, 

new studies will face similar challenges. In 

E3-PTSD, we submitted progress reports 

and held debriefings with the VA leadership. Our greatest impact to date has been 

the timely transfer of knowledge, which has 

allowed leadership to properly debate the 

study implications and incorporate them 

into consideration and formulation 

of policy. 

References

1. Weathers, F.W. et al. “Clinician-administered PTSD 

Scale: A Review of the First Ten Years of Research,” 

Depression and Anxiety 2001; 13:132-56.

2. World Health Organization. World Health Organization Disability Assessment Schedule WHODAS II. 

www.who.int/entity/healthinfo [serial online] 2000; 

Phase 2 Field Trials.

3. Jackson, J.C. et al. “Variation in Practices and Attitudes of Clinicians Assessing PTSD-Related Disability Among Veterans,” Journal of Traumatic Stress 2011; 

24(5):609-13.