Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

March 2012

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, M.D., M.C.R., Director

Suicide Risk Factors and Risk 

Assessment Tools: A Systematic 

Review

Investigators:

Principal Investigators: 

Elizabeth M Haney, M.D.

Maya Elin O’Neil, Ph.D., M.S.

Co-Investigators and Research Associates: 

Susan Carson, M.P.H.

Allison Low, B.A.

Kimberly Peterson, M.S.

Lauren M Denneson, Ph.D.

Chandra Oleksiewicz, M.D.

Devan Kansagara, M.D., M.C.R.
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Suicide Risk Factors and Risk Assessment Tools:

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PREFACE

Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA.

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Haney EM, O’Neil ME, Carson S, Low A, Peterson K, 

Denneson LM, Oleksiewicz C, and Kansagara D. Suicide Risk Factors and Risk 

Assessment Tools: A Systematic Review. VA-ESP Project #05-225; 2012.

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the Portland VA Medical Center, Portland OR funded by the 

Department of Veterans Affairs, Veterans Health Administration, Office of Research and 

Development, Quality Enhancement Research Initiative. The findings and conclusions 

in this document are those of the author(s) who are responsible for its contents; the 

findings and conclusions do not necessarily represent the views of the Department 

of Veterans Affairs or the United States government. Therefore, no statement in this 

article should be construed as an official position of the Department of Veterans Affairs. 

No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents 

received or pending, or royalties) that conflict with material presented in the report.
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Suicide Risk Factors and Risk Assessment Tools:

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TABLE OF CONTENTS

EXECUTIVE SUMMARY

Introduction ................................................................................................................................................... 1

Methods......................................................................................................................................................... 1

Data Synthesis............................................................................................................................................... 2

Peer Review................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

INTRODUCTION............................................................................................................................................... 8

Analytical Framework and Scope of This Report ......................................................................................... 9

METHODS

Topic Development...................................................................................................................................... 11

Search Strategy............................................................................................................................................ 11

Study Selection............................................................................................................................................ 12

Data Abstraction .......................................................................................................................................... 13

Quality Assessment ..................................................................................................................................... 13

Data Synthesis............................................................................................................................................. 14

Peer Review................................................................................................................................................. 15

RESULTS

Literature Flow ............................................................................................................................................ 16

Systematic Reviews..................................................................................................................................... 17

Key Question #1. What assessment tools are effective for assessing risk of engaging in suicidal selfdirected violence in Veteran and military populations?............................................................................... 17

Key Question #2. In addition to the risk factors included by current assessment tools, what other risk 

factors predict suicidal self-directed violence in Veteran and military populations? .................................. 20

Summary of Findings.................................................................................................................................. 26

SUMMARY AND DISCUSSION

Summary of Evidence by Key Question ..................................................................................................... 30

Limitations................................................................................................................................................... 33

Recommendations for Future Research....................................................................................................... 34

Conclusions ................................................................................................................................................. 35

REFERENCES ................................................................................................................................................... 36

TABLES

Table 1. Summary of Risk Factors and Associations with Suicide Attempts and Suicides................... 26

Table 2. Summary of Risk Studies......................................................................................................... 28

FIGURES

Figure 1. Suicide Prevention Analytical Model....................................................................................... 10

Figure 2. Literature Flow Chart............................................................................................................... 16
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Suicide Risk Factors and Risk Assessment Tools:

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APPENDIX A. Search Strategies............................................................................................................ 46

APPENDIX B. Study Selection Form.................................................................................................... 48

APPENDIX C. Criteria Used in Quality Assessment of Systematic Reviews...................... 49

APPENDIX D. Criteria Used in Quality Assessment of Primary Studies Related 

to Assessing Risk of Engaging in Suicidal Self-Directed Violence ......... 51

APPENDIX E. Criteria Used in Quality Assessment of Primary Studies Related 

to Additional Risk Factors to Predict Suicida l Self-Directed 

Violence............................................................................................................................... 52

APPENDIX F. Quality Rating of Systematic Reviews Using Oxman and Guyatt 

Criteria ................................................................................................................................ 53

APPENDIX G. Data Abstraction For Primary Studies Obtained From Good Quality

Systematic Reviews ......................................................................................................... 56

APPENDIX H. Summary of Systematic Review Results Related to Assessing Risk 

of Suicide From Gaynes et al., Mann et al., and Nice Revie ws................... 63

APPENDIX I. Data Abstraction For Primary Studies Related to Assessing Risk 

of Engaging in Suicidal Self-Directed Violence Among Military 

and Veteran Populations.............................................................................................. 64

APPENDIX J. Risk of Bias Ratings For Primary Studies Related to Assessing 

Risk of Engaging in Suicidal Self-Directed Violence Among 

Military and Veteran Populations .......................................................................... 66

APPENDIX K. Data Abstraction For Primary Studies of Factors to Predict 

Suicidal Self-Directed Violence in Military and Veteran 

Populations ......................................................................................................................... 68

APPENDIX L. Risk in Bias Ratings For Primary Studies of Factors to Predict 

Suicidal Self-Directed Violence in Military and Veteran 

Populations ......................................................................................................................... 83

APPENDIX M. Peer Review Comments/Author Responses .......................................................... 90

Appendix N. Abbreviations..................................................................................................................... 97

Appendix O. Excluded Studies.............................................................................................................. 98
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Suicide Risk Factors and Risk Assessment Tools:

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EVIDENCE REPORT

INTRODUCTION

Suicide is a major public health concern in the United States (US), claiming over 36,000 lives 

each year and nearly 100 lives each day.1 Suicide was the tenth leading cause of death in the US 

in 2009.1

 The rate is highest among 25 to 34 year-olds, for whom suicide is the second leading 

cause of death.43 For each suicide death, there are approximately 25 suicide attempts, also 

referred to as incidents of suicidal self-directed violence.44, 45 The lifetime risk of suicidal selfdirected violence for the general US population is estimated to be between 1.9 and 8.7 percent.45

Among Veterans and current military, suicide is a national public health concern. Recent 

estimates suggest current or former military represent 20 percent of all known suicides in the 

US,46 and the rate of suicides among Veterans utilizing Veterans Health Administration (VHA) 

services is estimated to be higher than the general population.47, 48 Among active duty soldiers 

in the Army, Army Reserve, and Army National Guard, rates are increasing and reached 20.2 

per 100,000 in 2008.49 Veterans returning from the Iraq and Afghanistan conflicts, referred to as 

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans, may be particularly 

at risk, although the limited available data has shown mixed results.2, 3 The enormity of the 

problem has led to several major public health initiatives and growing interest in suicide and selfdirected violence prevention.50-53

Approximately 32 percent of individuals make contact with a mental health care provider and 

77 percent make contact with a primary care provider during the year prior to suicide.54 In one 

Oregon study, 22 percent of Veterans who died by suicide had made contact with Veterans 

Affairs (VA) healthcare providers in the prior year.55

Although healthcare providers have an opportunity to identify at-risk individuals and engage 

them in treatment to reduce suicidal self-directed violence, many healthcare providers are 

uncertain how to assess for suicide risk.56, 57 Several risk factors for suicide and suicidal selfdirected violence have been identified, most notably older age, male gender, physical and 

mental health disorders (including depression and substance use disorders), familial and genetic 

influences, impulsivity, poor psychosocial support, and access to and knowledge of firearms.56, 

58-60 Several psychological autopsy studies of the events leading up to suicide have suggested the 

majority of individuals who die by suicide exhibit symptoms of depression or other mental health 

issues prior to death.61

The relative importance of some of these traditional risk factors, as well as the influence of 

population-specific risk factors, may be unique among military personnel and Veterans. The 

prevailing male demographic, along with high rates of post-traumatic stress disorder (PTSD), 

substance use disorders, and other mental health disorders, may especially contribute to the 

risk of suicidal self-directed violence in military and Veteran populations. In addition, several 

aspects of military experience can increase the risk for mental health and substance abuse, which 

in turn are risk factors for suicide.62 Other risk factors unique to the military experience could 

also contribute to overall suicide risk, including military rank, combat exposure, traumatic brain 

injury (TBI),22, 63 habituation to violence,64 and deployment-related stressors (e.g., strained or 
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Suicide Risk Factors and Risk Assessment Tools:

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long distance relationships, relocation, post-deployment adjustment).60, 65

Of course, many military and Veteran personnel will have one or more of these individual risk 

factors, but relatively few of them are truly at-risk for suicidal self-directed violence. Suicide 

risk assessment tools need to account for the relationship among these different risk factors and 

identify risk factors or combinations of risk factors that are particularly associated with suicidal 

self-directed violence. To be practically useful, risk assessment tools would identify a threshold 

beyond which preventive action should be taken and be brief enough to be conducted in primary 

care settings where many of the at-risk persons may be seen. Ideally, such tools would identify 

all persons truly at-risk for suicidal self-directed violence (i.e., have high sensitivity), while 

minimizing misidentification of persons who are not truly at high-risk (i.e., high specificity) 

because subsequent preventive therapies may be time-consuming and costly. Risk assessment 

tools should be able to, in other words, discriminate those at high- and low-risk for suicidal selfdirected violence. Given the rarity of suicide, this can be a difficult task. Estimates by Gaynes et 

al. suggest that under base-case scenario, with an assessment tool with 0.80 sensitivity and 0.70 

specificity applied to 10,000 patients (10 of whom will attempt suicide),5

 will have a positive 

predictive value of 0.3 percent (8 true-positives, 2 false-negatives and 2,997 false-positives). 

Using a tool with 0.89 sensitivity raises the positive predictive value to 3.8 percent.5 These 

challenges require an enhanced understanding of suicide risk assessment in military and Veteran 

populations. The objectives of this review, therefore, are to review the available evidence for risk 

factors and assessment tools developed for use in healthcare and other community settings, and 

tested with Veteran and military populations.

ANALYTICAL FRAMEWORK AND SCOPE OF THIS REPORT

In order to provide evidence for clinical practice guideline development, this report reviews 

available evidence about risk factors and risk assessment tools within Veteran and military 

populations.

The model below (Figure 1) summarizes the analytical framework used in this report for 

Veteran and military populations. We focus on individual-level risk factor determination and 

assessment; that is, clinically relevant risk factors that can help a provider determine that a 

patient has increased risk, and assessment tools that are appropriate for clinical risk assessment 

to predict suicide outcomes. Though the focus of the report is on suicide prevention, we include 

as outcomes any type of suicidal self-directed violence defined as, “Behavior that is selfdirected and deliberately results in injury or the potential for injury to oneself. There is evidence, 

whether implicit or explicit, of suicidal intent.”66, 67 We use this terminology throughout this 

evidence report when possible; however, when describing results from primary studies, we use 

terminology as reported in the original articles in order to describe outcomes consistent with the 

primary studies.
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

tion Analytical Model

Population-level interventions

• Help seeking resources (e.g., crisis 

lines)

• Public education (e.g., PSAs on 

suicide awareness)

• Environmental modification/means 

restriction (e.g., gun safety laws, bridge barriers)

• Universal screening (e.g., standardized intake tools) Intermediate outcomes • Change in mental health 

symptoms

• Change in substance use• Change in suicidal ideation• Change in life stressors• Change in support system

Distal health outcomes

• Suicide

• Suicidal/undetermined selfdirected violence

Provide timely and 

appropriate intervention

• Pharmacotherapy (e.g., 

anti-depressants, mood stabilizers, anti-psychotics, omega-3s, other pharmacotherapy)

• Psychotherapy (e.g., 

Cognitive Behavioral Therapies, Dialectical Behavior Therapy, Psychodynamic therapies, other psychotherapy)

Key Question 2: 

Risk factors for 

prediction of suicide in 

Veterans and members of 

the military

Provide referral/

follow-up services

• Timely, appropriate 

intervention referrals

• Case management• Provider contact (e.g., 

postcards, phone calls)

• Support services (e.g., 

family/peer engagement)

Known 

risk 

factor(s) 

absent

Known risk factor(s) 

present

• Depression• Substance Use Disorder• Other mental health 

disorder

• Recent stressors• Family history of suicide• History of suicide 

attempt(s)

Key Question 1:

Risk assessment in 

Veterans and

 members of the 

military
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Suicide Risk Factors and Risk Assessment Tools:

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METHODS

TOPIC DEVELOPMENT

This project was requested by the VA/Department of Defense (DoD) Evidence Based Practice 

Working Group (EBPWG) to support the development of clinical practice guidelines for suicide 

prevention. The VA/DoD suicide prevention EBPWG requested a systematic review of literature 

related to suicidal self-directed violence as defined by Crosby et al. and Brenner et al.66, 67

published since two prior reports on the topic by Mann et al. and Gaynes et al.4, 5 The workgroup 

requested a review that focuses on countries and populations most representative of US Veteran 

and military populations. 

A report on self-harm was recently conducted by the National Institute for Health and Clinical 

Excellence (NICE) and released in draft form during the writing of this current report.6 The 

NICE report focuses on self-harm in general within the civilian population. Our report examines 

suicidal self-directed violence specifically rather than self-harm in general, and focuses on US 

Veterans and members of the military rather than on a civilian population. To be comprehensive, 

we summarize findings from the earlier (Mann and Gaynes) and concurrent (NICE) reviews in 

our report to highlight broader, civilian-focused evidence, though our report focuses on evidence 

specifically related to Veterans and members of the military. A technical panel comprised of 

members of this workgroup as well as VA leaders in the field of suicidology provided input.

The final key questions developed a priori in conjunction with the EBPWG are: 

Key Question #1. What assessment tools are effective for assessing risk of engaging in suicidal 

self-directed violence in Veteran and military populations?

Key Question #2. In addition to the risk factors included by current assessment tools, what other 

risk factors predict suicidal self-directed violence in Veteran and military populations?

SEARCH STRATEGY

To identify relevant systematic reviews and controlled trials, we searched PubMed, PsycINFO, 

the Cochrane Database of Systematic Reviews®, and the Cochrane Central Register of Controlled 

Trials®. We used a similar search strategy as Mann et al.,4 and covered the period from January 

2005 to November 18, 2011 to identify newer studies that would not have been included in this 

prior review. We also included risk assessment, screening and validity, and Veteran populations 

as search terms (Appendix A). We limited the search to peer-reviewed articles involving human 

subjects and published in the English language that were not included in previously published 

systematic reviews on the topic.4, 5 We obtained additional articles from systematic reviews, 

reference lists of pertinent studies, reviews, editorials, and consulting experts. Additionally, 

though the focus of the requested review was on risk factors and assessment tools related to 

suicide, we included any articles reporting on suicidal self-directed violence as an outcome to 

include as comprehensive a list of articles as possible.
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STUDY SELECTION

Titles and abstracts were reviewed by doctoral level investigators and project research associates 

trained in the critical analysis of literature. Eligibility of full-text articles was independently 

assessed by two reviewers, and disagreements were resolved by consensus. 

To determine the evidence base for the assessment of risk for engaging in suicidal self-directed 

violence and identifying additional risk factors for suicidal self-directed violence, we examined 

studies with any design, including systematic reviews, randomized controlled trials, observational 

studies and case control analyses. Assessment of new or emerging risk factors requires evaluation 

within the context of previously known risk factors. Some new risk factors may act through or as 

a result of other existing risk factors. Thus, controlling for known risk factors is an essential part 

of any study that seeks to propose a new clinical risk factor.68 As such, we have included here only 

studies that evaluate risk factors using analytic techniques that account for at least one of several 

well-established risk factors (established a priori): suicidal ideation, history of suicide attempts, 

substance use disorder, or history of any mental health diagnosis. Therefore, studies that only reported 

rates of suicide in a general population were excluded; however, studies reporting rates of suicide 

in a population of people who all had prior substance use disorders or mental health diagnoses were 

included. Likewise, if a study enrolled patients from a randomized controlled trial and failed to 

control for treatment allocation, it was excluded. We excluded studies that used genetic testing to 

predict suicide, and studies that evaluated post-mortem tissue to assess biochemical or pathologic 

correlates with suicide. Our review was designed to detect the highest quality recent evidence relating 

to populations that most closely approximate US Veteran and military populations. Therefore, though 

we used selection criteria similar to those used in the reviews by Mann et al., Gaynes et al., and NICE 

2011,4-6 our review differs from these reviews in excluding research conducted in countries dissimilar 

to the US, and excluding studies on civilian populations. Additionally, the NICE report addresses 

primarily risk assessment and risk factors related to repetition of self-harm. 

Below are listed the specific inclusion criteria used to select studies for each Key Question, 

respectively: 

• Key Question #1 – Primary literature review of studies with the following characteristics: 

• Patients: Any Veteran and/or military patient subgroup from the US, United Kingdom (UK), 

Canada, New Zealand, and Australia.

• Intervention: Not applicable to this key question.

• Comparator: No intention to limit by comparator.

• Outcomes and measures: (1) Proportion of individuals in each risk group who exhibit suicidal 

self-directed violence, including suicide attempt and suicide and not including self-directed 

violence ideation and undetermined or non-suicidal self-directed violence (i.e., behavior 

resulting in injury for which there is unclear or no implicit or explicit evidence of intent to 

die); and (2) standard measures of discrimination and reclassification for risk assessment tools.

• Timing: Any length of follow-up.

• Setting: US Veteran or military inpatient or outpatient setting.

Key Question #2 – Primary literature review of studies with the following characteristics: 

• Patients: Any Veteran and/or military patient subgroup from the US, UK, Canada, New 

Zealand, and Australia.
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Suicide Risk Factors and Risk Assessment Tools:

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• Intervention: Not applicable to this key question.

• Comparator: No intention to limit by comparator.

• Outcomes and measures: Proportions or relative risk (RR) ratios for suicidal self-directed 

violence, including suicide attempt and suicide and not including self-directed violence 

ideation and undetermined or non-suicidal self-directed violence (i.e., behavior resulting in 

injury for which there is unclear or no implicit or explicit evidence of intent to die).

• Timing: Any length of follow-up.

• Setting: US Veteran or military inpatient or outpatient setting.

• The complete study selection form, including abstract and full-text codes, is included in 

Appendix B.

DATA ABSTRACTION

For controlled trials, we abstracted information on setting, population characteristics, risk factors 

measured or included in assessment tool, comparison group (if any), number of subjects, length 

of follow-up, outcome assessment methods, and results. For systematic reviews, we abstracted 

information on the objective of the review, time period and databases searched, excluded studies 

and eligibility criteria used; and for all included studies that also met our eligibility criteria, we 

also abstracted information on study designs, country, sample size, population, and main results. 

For observational studies analyzing assessment tools, we abstracted information on study design, 

population and setting, outcome, risk factor included in assessment calculation, results, results 

of validation in a second group, and appropriateness for primary care settings. For observational 

studies assessing risk factors, we abstracted information on study design, aim of the study, 

sample size, data source and sample time frame, population characteristics, comparison group 

(if any), risk factors measured, method of measurement of risk factors and outcome, length of 

follow-up/observational, statistical analysis methods/control for confounding, and results. 

QUALITY ASSESSMENT

We assessed the quality of systematic reviews using predefined criteria established by Oxman 

and Guyatt in 1991.8

 The Oxman and Guyatt quality rating system consists of nine questions 

that involve assessing the adequacy of systematic review methods including searching, reporting 

of inclusion criteria, study selection, validity assessment, data synthesis, and conclusions. Each 

question is scored as ‘yes,’ ‘partially/unclear,’ or ‘no’. The overall quality is scored based on a 

scale of 1 to 7, where 1 represents the presence of extensive flaws and 7 represents the presence 

of minimal flaws (Appendix C). 

We assessed the risk of bias of primary studies using modified versions of the tools described 

in Harris et al. 2001 and Hayden et al. 2006.9, 10 Adequacy for each domain was rated as ‘yes,’ 

‘unclear/unsure,’ or ‘no.’ The overall risk of bias for each controlled trial is then rated as ‘low,’ 

‘unclear,’ or ‘high’ based on the reviewer’s judgment of the plausibility that the biases have 

seriously weakened their confidence in the results (Appendices D and E). 

Two reviewers independently assessed the quality of each study. Reviewers then compared 

their ratings and resolved all differences through discussion or by consulting a third party when 

consensus could not be reached. Note that it is possible for a study that is included in both 
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Suicide Risk Factors and Risk Assessment Tools:

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the risk assessment tool section and the risk factor section (example, Hartl 2005) to be rated 

differently for risk of bias as the evidence pertains to each section because of differences in 

the risk of bias criteria for risk assessment studies versus risk factor studies. Domains for risk 

factor studies included: adequacy of population description, non-biased selection, minimal 

loss to follow-up, adequate (un-biased) risk factor assessment, adequate (un-biased) outcome 

measurement, adequate sample size (number of outcome events), adequate statistical adjustment, 

and number of confounders adjusted for in the analysis (must have adjusted for at least 1 of 4 

necessary risk factors – any mental health diagnosis, history of suicide attempt, suicidal ideation 

or substance abuse). Domains for risk assessment tool studies included: adequate population 

description, non-biased selection, minimal loss to follow-up, standardized method of risk factor 

assessment and scoring clearly described, unbiased risk factor assessment by independent 

assessors, adequate outcome measurement, unbiased outcome measured by independent 

assessors, and adequate accounting for potential confounders.

DATA SYNTHESIS

We constructed evidence tables showing study design, population and setting, and risk factor 

measured or included in assessment; methodological quality; and outcomes, organized by key 

question and study design. We analyzed studies to compare their characteristics, methods, 

and findings. For risk assessment tools, we graded strength of evidence based on the guidance 

established for the Evidence-based Practice Center Program of the Agency for Healthcare 

Research and Quality.69 We compiled a summary of findings for each key question and study 

design based on qualitative synthesis of the findings. The heterogeneity in study population, tool 

characteristics, and patient population among studies precluded meaningful quantitative analysis. 

For risk factor studies, we summarized the studies in a table displaying population, outcome 

and risk of bias (Table 2); we compiled the evidence about risk factors into a table that lists the 

strength of evidence according to each risk factor (Table 1).

We also report findings as described in the prior systematic reviews by Mann et al. and Gaynes et 

al.4, 5 Because our review was designed to be an update to these reports and because of different 

scopes of the reports, we have not re-evaluated the source studies included in their reports. 

Additionally, we include in our synthesis findings from the NICE 2011 draft report on self-harm,6 a 

review with a similarly up-to-date literature search to this current report, though a more broad focus 

on self-harm in all populations including civilians. Due to the differences in scope and methods in 

these other reports, data synthesis of their findings is limited to a qualitative summary of findings.

Our review was designed only to examine studies published since June, 2005, so we consider the 

findings from the Mann et al. and Gaynes et al. reviews to assess the contributions of pre-2005 

literature on the overall strength of evidence.4, 5 We also summarize the information on repeated 

self-harm (including suicide) reported in the NICE 2011 review.6

 However, because these 

reviews used different quality assessment and data synthesis methodology, as well as having 

different scopes (e.g., including civilian populations, or focusing on repeated self-harm), the 

combination of results from the reports should be interpreted with caution.
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PEER REVIEW

A draft version of this report was reviewed by seven technical experts as well as clinical 

leadership. Their comments and our responses are presented in Appendix M.
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RESULTS

LITERATURE FLOW

We reviewed 16,426 titles and abstracts from the electronic search, and an additional 95 from 

reference mining for a total of 16,521 references. After applying inclusion/exclusion criteria 

at the abstract level, 15,743 references were excluded. We retrieved 778 full-text articles for 

further review and another 732 references were excluded. We identified a total of 46 references 

for inclusion in the current review, including 30 observational studies and 14 systematic reviews 

(reported in 16 publications). We grouped the studies by key question and study design. Figure 2 

details the number of references related to exclusion criteria and publication type. 

Figure 2. Literature Flow Charta

732 full-text articles excluded

• 22 non-English language

• 72 ineligible country

• 110 ineligible outcome

• 49 did not evaluate risk 

factors or assessments

• 191 ineligible publication type

• 129 ineligible systematic 

review due to limitations in 

quality

• 10 ineligible nonsystematic 

regulatory agency analysis

• 26 did not account for major 

potential confounders

• 123 primary articles about 

risk, not a Veteran or military 

populationb

16,426 records identified from database 

searches after removal of duplicates

44 studies reported in 46 publications 

included in qualitative synthesis

• 30 observational studies

• 14 systematic reviews reported in 16 

publications

16,521 records screened

778 full-text articles assessed for eligibility

95 additional records identified through other 

sources

15,743 records excluded at 

abstract levelb

a

 Modified from the PRISMA flow diagram.70

b

 1,336 primary risk articles in a non-Veteran or military population were excluded after reviewing the 

publication’s abstract; 123 were excluded after reviewing the full publication.
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Suicide Risk Factors and Risk Assessment Tools:

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SYSTEMATIC REVIEWS 

We identified 34 systematic reviews (reported in 38 publications) of risk assessment tools and 

risk factors associated with suicidal self-directed violence.71-108 Using the Oxman and Guyatt 

criteria, we assessed these reviews for risk of bias (Appendix F).8

 Fourteen reviews had minimal 

flaws (a rating of 6 or 7); these are summarized in Appendix G.74, 76, 79, 83, 86, 88, 89, 91, 94-97, 104, 105, 107, 

108 The usefulness of these reviews to this report is limited, however; 6 of 14 reviews did not 

include any studies meeting our eligibility criteria, and no review focused on Veteran or military 

populations.

KEY QUESTION #1. What assessment tools are effective for assessing 

risk of engaging in suicidal self-directed violence in Veteran and 

military populations?

Summary of prior reviews on risk assessment tools in non-Veteran and nonmilitary populations

In order to provide background on the literature prior to 2005 and in civilian populations, we 

highlight findings from several existing reviews on suicide assessment tools in any population. 

These reports include systematic reviews of suicide by Mann et al., Gaynes et al., and one on 

repetition of self-harm by NICE in 2011;4-6 as well as two non-systematic literature reviews that 

provide comprehensive lists of over 60 existing suicide assessment tools for adults and older 

adults by Brown, and for children and adolescents by Goldston.11, 12

Brown and Goldston11, 12 are non-systematic reviews that describe the psychometric properties 

and validation studies for measures designed to assess suicidal ideation and behavior. The 

Brown report cites numerous measures that have demonstrated adequate internal reliability 

and concurrent validity, though it highlights the Scale for Suicidal Ideation and the Beck 

Hopelessness Scale as two of only very few measures that have shown associations with death 

by suicide. The Goldston paper reports that many promising measures for use in child and 

adolescent populations have insufficient psychometric data, and are in need of further research. 

Goldston specifically highlights the need for prospective studies examining the association 

between these assessment tools and death by suicide. Due to the non-systematic nature of 

the Brown and Goldston papers,11, 12 and the fact that their specific inclusion criteria were 

different from the criteria used for our current review, findings should be interpreted as such, 

and not combined in an additive manner with findings from this report. However, researchers 

and providers seeking information on existing assessment tools will find these reports to be a 

resource for descriptive and validity information on such tools.

The three systematic reviews, Mann et al., Gaynes et al. and NICE 2011,4-6 each highlight the 

need for further prospective research to establish the effectiveness of these assessment tools in 

predicting suicidal self-directed violence. The authors all note that current research is insufficient 

to determine definitively whether or not there is a benefit in implementing existing screening 

tools for the prevention of suicide. The NICE 2011 review is the most recent and comprehensive 

review of suicide risk assessment tools. It describes findings from six cohort studies that examine 

tools for prediction of death by suicide among people with prior non-fatal self-harm. The authors 
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conclude that several limitations of the whole body of literature preclude recommendation of 

these suicide risk assessment tools for use in clinical practice: short follow-up periods of the 

studies, inadequate sample sizes needed to detect effects on low base-rate outcome, and overall 

high rates of false positive identification of individuals as being at risk for suicide. This report 

also investigated scales designed to predict self-harm and described similar limitations among 

these scales. Specifically, they note that low positive predictive values for these scales indicate 

that individuals are likely to be over-identified as being at risk, which has the potential to result 

in unnecessary intervention for some individuals. Overall, the findings from the Mann, Gaynes, 

and NICE reviews concur in their reports of limited evidence available on the effectiveness of 

suicide risk assessment measures in prevention of suicidal self-directed violence. We summarize 

assessment results from these reports in Appendix H, describing the scope as well as the findings.

Primary studies of risk assessment tools in Veteran and military populations 

Given the limited evidence available on effective suicide risk assessment tools, we examined the 

best available evidence specifically related to Veteran and military populations. We included five 

articles13-17 that met our inclusions criteria and described assessment tools used within military or 

Veteran populations (Appendix I), three of which had methodological flaws resulting in a high 

risk of bias,13, 14, 16 and two of which were rated as having unclear risk of bias (Appendix J).15, 17

Hendin et al. examined a brief screening tool, the Affective States Questionnaire (ASQ), as a 

predictor of suicidal behavior.15 This study was conducted among a population of 283 Veterans 

receiving inpatient or outpatient services at a Veterans Affairs Medical Center (VAMC). The 

ASQ increased odds of prediction of future suicidal behavior by 2.4 in a logistic regression 

model adjusting for sex, substance abuse, and severity of depression. Using a cutoff of ≥3, the 

ASQ resulted in sensitivity of 0.60 and specificity of 0.74 in this population. The authors report 

preliminary validity information for the ASQ, and the study obtained a rating of unclear risk 

of bias because of insufficient information on how patients were selected to participate and no 

information on assessor blinding when assessing the suicidal behavior outcome. Because of the 

unclear risk of bias and relatively small sample size, this one study provides insufficient evidence 

that the ASQ predicts suicidal behavior. However, because of the initially promising results even 

after adjusting for known risk factors, as well as the potential utility of such a brief screening tool 

in primary care settings, future research on the predictive power of the ASQ is warranted.

Tiet et al. investigated the use of the Addiction Severity Index (ASI), a lengthy structured clinical 

interview designed to be used as an intake interview for a substance abuse treatment program.17

Their study examined over 34,000 Veterans who were assessed for intake as part of substance 

abuse treatment at 150 VAMCs nationwide. This assessment tool is not ideal for settings that 

require brief screening tools, though VAs used to use this assessment routinely, and, therefore, 

the information is readily available in a large number of Veteran medical charts for those 

Veterans who received substance abuse treatment in the past. As such, the information provided 

in this article is helpful in establishing risk factors based on an entire population of Veteran 

responses to routine intake items within the timeframe covered in the study. The authors report 

a decision tree, delineating all significant risk factors to predict future suicidal behavior. The 

significant predictors were suicide attempt history, suicide ideation history, recent alcohol abuse, 

recent cocaine abuse, violent behavior, hallucinations, and employment status. This article was 
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rated as having an unclear risk of bias, largely because of the unclear independence of assessors; 

however, because of the large sample size (i.e., the entire population of Veterans who completed 

a structured and electronically documented substance abuse intake process), this single study 

provides moderate strength of evidence for the reported risk assessment capabilities of the ASI. 

As noted, however, the ASI is no longer routinely used in VA settings.

Breshears et al. investigated the use of the Personality Assessment Inventory (PAI) in a 

population of 154 Veterans with a history of TBI.13 The PAI is a lengthy assessment tool designed 

to be administered by a psychologist in the context of an in-depth psychological assessment. 

Two PAI subscales are designed to assess aspects of suicidality, and these two subscales were 

investigated as predictors of future suicidal behavior as documented in patient’s charts. Breshears 

evaluated one of the subscales of the PAI, the Suicide Potential Index (SPI), and found that it 

predicted suicidal behavior after controlling for other risk factors. Although this measure is 

frequently used in VA settings as part of psychological assessments, it is not well suited for use 

as a brief screening tool and, therefore, would be less useful in primary care settings. The lack 

of applicability to primary care settings is related to the lengthiness of the overall measure, the 

computer scoring methods, and the training/educational requirements required for interpretation 

and scoring. The various subscale items are embedded within the overall assessment tool, 

making partial administration of specific subscales difficult if not impossible. The results suggest 

potential additive predictive power of the SPI subscale. However, the high risk of bias rating 

of this study due to lack of assessor blinding and other methodological flaws does not allow 

for strong conclusions on the basis of this study. Although lack of assessor blinding may be 

less concerning with more objective outcomes such as suicide, this study used chart review to 

document suicide attempts, making lack of blinding a potential source of bias. More research 

to confirm these preliminary findings regarding the use of the SPI subscale would be necessary 

before recommending its use in a clinical setting. 

Nademin et al. describe the Interpersonal Psychological Survey (IPS), a 34-item measure, which 

they report as being associated with increased odds of suicide (Odds Ratio [OR]: 1.27).16 This 

study, however, was rated as having a high risk of bias due in large part to the inability to account 

for confounders and differences in assessment techniques between groups. The two groups they 

examined were 60 members of the Air Force who died by suicide and a matched sample of 122 

members of the Air Force. Due to the retrospective nature of the study investigating suicide 

as the primary outcome, assessors estimated scores on the assessment tools for the groups of 

participants who died by suicide, whereas the control group participants completed the measures 

by self-report. This difference in assessment techniques and other confounders associated with 

the groups being compared results is insufficient evidence that the IPS predicts suicide.

Hartl et al. reported findings for a sample of 630 male Veterans diagnosed with PTSD and 

participating in a residential treatment program.14 They examined the Beck Depression 

Inventory-II (BDI), a 21-item, commonly used depression screening tool which includes 

an item asking about suicidal ideation. This measure, due to its brevity, frequent usage, and 

ability to be administered, scored, and interpreted by a variety of providers, has potential for 

widespread implementation in VA and military settings. Though the authors found that previous 

suicide attempt (four months prior to intake) was the strongest predictor of future suicide 

attempt following discharge, they report that BDI-II score was also a significant predictor of 
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future suicide attempt. They reported model sensitivity of 0.63 and specificity of 0.80 in their 

exploratory sample of 409 Veterans. The replication study examining data on the remaining 221 

Veterans used the cutoffs established in the exploratory study. Contrary to the exploratory model, 

the replication model resulted in sensitivity of 0.11 and specificity of 0.84. Overall, this study 

provides insufficient evidence for the BDI-II in predicting future suicide attempts in a Veteran 

population with PTSD due to the inconsistent results as well as the high risk of bias rating of this 

study.

KEY QUESTION #2. In addition to the risk factors included by current 

assessment tools, what other risk factors predict suicidal selfdirected violence in Veteran and military populations?

Summary of prior reviews on risk factors for suicide in non-Veteran and nonmilitary populations

Though existing systematic reviews on this topic were outside the scope of this report due to 

their focus on civilian populations, in order to provide a comprehensive report on risk factors for 

suicide, we highlight findings from existing systematic reviews of risk factors in any population. 

These include systematic reviews on suicide by Mann et al., Gaynes et al., and on repetition of 

self-harm by NICE in 2011.4-6 Mann and Gaynes did not address literature assessing the strength 

of individual risk factors, but the NICE report did perform a comprehensive review and metaanalysis of risk factors. The NICE report methodology differs from that used for this report in 

several ways: 1) they included only prospective studies evaluating risk for repetition of selfharm; 2) they included studies from other countries outside the scope of this report; and 3) they 

included studies that were minimally adjusted for confounders (other risk factors that might 

explain the association - e.g., mental health diagnoses; some studies did not assess or adjust for 

mental health diagnoses in evaluating other risk factors for suicide).

The NICE report found that the following factors predicted non-fatal repetition of self-harm 

in adults:6 prior self-harm and depression symptoms, schizophrenia and related symptoms, 

alcohol misuse, other psychiatric history, unemployment and “registered sick”, female gender 

(mixed and poor quality evidence), unmarried status (narrative evidence only; not predictive 

in pooled analysis), and younger age. The following symptoms predicted suicide among adults 

with prior self-harm: suicide intent/intent to die, male gender, psychiatric history, older age, 

violent methods of self-harm, physical health problems (mixed evidence), and alcohol abuse 

(mixed evidence). Risk factors for repeated self-harm among young people were similar to those 

identified for adults. Given these differences between our report and the NICE review, these 

findings should be interpreted with some caution.6

Primary studies on risk factors for suicide in Veteran and military populations

We identified 26 studies that evaluated risk factors to predict suicide behavior outcomes 

(Appendix K).14, 18-42 Table 1 in this section lists all risk factors identified and the studies that 

contributed to evidence for that risk factor. Table 2 lists all studies with information on study 

design, population, outcome and risk of bias for each included study.
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Studies of risk factors for suicide were longitudinal, cross-sectional and case-control in their design. 

Many utilized existing VA databases linked with clinical (inpatient or outpatient), administrative, or 

large survey databases either alone or linked with another data sources. The populations represented 

in these studies are US Veterans in 18 studies, active duty US military personnel in four studies and 

other military populations in four studies. Outcomes include death by suicide in 15 studies, selfreported suicide attempts in 11 studies, and objective suicidal behavior assessed by chart review or 

clinician referral, or admission for suicide attempt in two studies. 

Risk of bias for the 26 identified studies is included in Appendix L. Four studies had a high risk 

of bias and, therefore, are not discussed further in this report.33, 34, 39, 40 The remaining 22 studies 

were rated as having unclear risk of bias. No studies had low risk of bias, a determination that 

requires that a study satisfy all quality criteria. Limitations of the studies evaluated here that 

accounted for high or unclear risk of bias include: assessment of suicidal behavior by chart 

review only, a method that is biased by whether the provider chooses to document suicidal 

behavior; use of ICD-9 codes for risk factor assessment; assessment of suicide attempts by selfreport; failure to report specific details of recruitment process (how many screened, how many 

agreed to participate and actually provided data); failure to report on the handling of missing 

data; and recruitment of potentially biased study population (as in patient sample with nonrandom treatment assignment when medication is the risk factor). As explained in the Methods 

section, we excluded studies that had inadequate control for potential confounding variables and 

randomized controlled trials that did not account for treatment group. The remaining studies are 

reported below.

Studies that assess risk factors for self-reported suicide attempts

Longitudinal designs

Two studies that utilized a self-reported suicide attempt outcome were longitudinal.14, 28 Hartl 

et al. enrolled male Veterans who were entering a residential treatment program for PTSD. 

Predictive variables were obtained at enrollment in the program and suicide attempts were 

assessed four months following discharge from the program. Having attempted suicide in the 

four months prior to enrollment was the best predictor of suicide attempt following discharge. 

Among those who had not attempted suicide in the four months before enrollment, suicide 

attempts following discharge were predicted by depressive symptoms (based on scores on the 

BDI).14 No data are provided about how various levels of BDI scores predict suicide attempts.

Ilgen et al. reported on how the ASI109 administered within two weeks of entry into a VA 

addiction treatment program predicted suicide one year later.28 Factors that predicted suicide 

attempts were: elevated suicidal/psychiatric symptoms based on the ASI, alcohol problems, 

and cocaine-adjusted life years; protective factors were: involvement with the criminal justice 

system and the number of days of participation in substance use disorder treatment.28 For this 

study, the authors used factor analysis to create the variable, “suicidal/psychiatric symptoms,” 

by combining four other positively correlated and overlapping variables: number of psychiatric 

problems in the 30 days prior to baseline, number of previous inpatient psychiatric treatment 

episodes, whether the patient reported being on psychiatric medications at baseline, and a 

variable for lifetime suicidality that was derived from lifetime suicidal ideation and lifetime 

suicide attempts.
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Cross-sectional designs

Five studies assessed self-reported suicide attempts using a cross-sectional study design and were 

rated as having unclear risk of bias.18, 19, 36, 37, 42 Two of these used active duty military Canadian 

military personnel.18, 19 Evaluating specific types of trauma, Belik et al. 2009 found that suicide 

attempts among men were associated with having purposely injured or killed, toxic chemical 

exposure, and life-threatening illness; and being a civilian in religious terror. Suicide attempts 

among women were associated with witnessing a man-made disaster, being a victim of child 

abuse or other abuse, witnessing domestic violence or being stalked.18 In the second study, 

Belik at al. 2010 found that depressive episodes, social phobia, alcohol dependence, generalized 

anxiety disorder and PTSD were associated with increased odds of suicide attempt.19

Tiet et al. examined data from over 33,269 men seeking treatment for substance use disorders, 

psychiatric disorders or both from the VA healthcare system.37 In multivariate logistic regression 

models of men, suicide attempt within the past 30 days was significantly associated with sexual 

abuse (OR 2.08) and physical abuse (OR 2.38) in the past 30 days, lifetime sexual abuse (OR 

1.33) before the past 30 days, psychotic disorder (OR 1.48), depressive disorder (OR 2.38), 

PTSD (OR 1.37), other anxiety disorder (OR 1.45), and personality disorder (OR 1.74). Alcohol 

abuse or dependence, drug abuse or dependence, marital status, age, and lifetime physical abuse 

prior to the past 30 days were not significantly associated with suicide attempts.37

Thomsen et al. surveyed 2,116 active duty military personnel in the US Marine Corps and US 

Navy serving in the US, half of whom had been combat deployed, and questioned them about their 

behaviors: 1) as a civilian, 2) prior to combat deployment, and 3) subsequent to combat deployment.36

Those who reported a prior suicide attempt had significantly higher odds of a subsequent suicide 

attempt (adjusted OR 8.58). Marital status (being divorced, separated or widowed) was the only 

other significantly associated potential risk factor (OR 3.90). This model included gender, age, rank, 

education, and combat deployment but no variable to account for psychiatric illness.36

Pettit et al. evaluated 298 men and women enrolling in an intervention trial for suicidality 

recruited from clinics, inpatient wards and the emergency room of a major US Army Medical 

Center.42 This cross-sectional analysis was designed to evaluate the interaction between negative 

life events and very early onset psychiatric illness (bipolar disorder, anxiety and major depressive 

disorder [MDD]). Negative life events were associated with self-reported suicide attempts in 

those with very early onset anxiety, very early onset MDD, and those without any history of very 

early onset psychiatric disorder. The interaction term for negative life events and very early onset 

bipolar disorder was significant, suggesting that very early onset bipolar disorder accounts for the 

association between negative life events and self-reported suicide attempts in this group.42

Studies that assess risk for objectively measured suicide attempts

Two studies have assessed suicide attempts using an objectively measured outcome rather than 

self-report, both using retrospective study designs.

Retrospective Designs

Brenner et al. performed a case control study using Veterans with a history of suicide identified 

from electronic medical records (EMR) of a VA mental health clinic and age/gender matched 
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controls.21 Having chart diagnoses of both PTSD and TBI increased the odds of suicide 

compared with those who had TBI only (OR 3.29), and increased the odds compared to 

having neither PTSD nor TBI (OR=2.54). In models accounting for both PTSD and TBI, 

PTSD was independently associated with suicide but TBI was not.21 Thus, PTSD appears to be 

independently associated with suicide attempts, and also appears to increase the odds of a suicide 

attempt among patients with TBI.

Using a retrospective chart review of randomly selected medical charts from those admitted to 

a US Army hospital with suicidal behaviors (n=191), Cox et al. evaluated predictors of suicide 

behaviors.23 Admission for suicidal behavior (as opposed to suicidal ideation) was associated 

with three types of childhood trauma (sexual abuse, domestic violence and other trauma). When 

this model was further adjusted for “other trauma,” those associations were no longer significant 

and indeed this model resulted in no significant risk factors.23 This study was assessed to have 

unclear risk of bias because all risk factors including trauma were evaluated with chart review.

Studies that assess risk factors for suicide

Thirteen studies evaluated risk factors for suicide. Many of these confirmed the suicide by using 

the National Death Index (NDI) to identify the person and cause of death; others used military 

records and International Classification of Diseases, Tenth Revision (ICD) chart diagnoses. 

Longitudinal studies

Eleven studies with death by suicide as the outcome used a longitudinal analysis to assess 

the contribution of risk factors.22, 24-27, 29, 30, 32, 35, 38, 41 Longitudinal analysis implies that the risk 

factor was known to occur prior to the outcome. In the case of a suicide death outcome, this 

will nearly always be the case, independent of whether the potential risk factors were assessed 

retrospectively (from charts after the time of the suicide) or prospectively (at baseline, prior to 

suicide). Prospective data collection contributes to lower risk of bias overall. 

The studies in this group evaluated the following potential risk factors: PTSD, TBI, psychiatric 

diagnoses, severe pain, and two health services measures: quality of care measures from recent 

psychiatric admissions and timing of follow-up following discharge after psychiatric admission. 

The studies with longitudinal analysis are reviewed in this section, grouped by their primary 

variable of interest. In most/all cases, other variables were also included and assessed. 

Psychological factors. Several studies by Ilgen et al. evaluate psychological factors using 

distinct populations and methods. One of these studies utilized data from 3,291,891 Veterans 

who used VA services in fiscal year (FY) 1999 and were alive at the start of FY 2000 to evaluate 

associations between psychiatric diagnoses and risk of suicide over the next six years. They 

found that both male and female Veterans diagnosed with any psychiatric condition were more 

likely to die by suicide than their counterparts who had no psychiatric diagnoses (Hazard Ratio 

[HR] for males: 2.50; 95% Confidence Interval [CI], 2.38 to 2.64; HR for females 5.18; 95% 

CI, 4.08 to 6.58). Indeed, the risk of suicide was increased for those with alcohol abuse or 

dependence, drug abuse or dependence, bipolar disorder, depression, other anxiety, PTSD and 

schizophrenia (age adjusted models, HR higher for females than males in every instance). Ilgen 

et al. did not evaluate all psychiatric diagnoses together in a multivariate model.25 This study was 
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determined to have unclear risk of bias based on lack of reporting of missing data and assessment 

of risk factors by use of ICD-9 codes.

Ilgen et al. evaluated Veterans with substance use disorders for predictors of violent compared 

with non-violent suicide compared to controls without suicide over four years (854 suicides 

and 4,228 controls). Major depression, other anxiety disorders, bipolar disorder, PTSD, 

schizophrenia, personality disorders and the presence of more than one mental disorder were 

predictive of both violent and non-violent suicide. Alcohol, cocaine, opiate, and multiple 

substance use disorders were associated with a higher risk of non-violent suicides compared to 

violent suicides. None of the factors evaluated were significant for prediction of violent suicide 

compared to non-violent among those who died by suicide.26 This study was determined to have 

an unclear risk of bias based on lack of reporting of missing data and assessment of risk factors 

by the use of ICD-9 codes.

In a separate analysis, Ilgen et al. evaluated 887,859 patients from the VA’s National Registry for 

Depression (NARDEP) for suicide risk factors, specifically race and substance abuse. Risk factors 

were evaluated between April 1999 and September 2004, and the suicide could have occurred at 

any time during the study period or in the one year following the study period (total follow-up time 

of up to 6.5 years, n=1892 suicides). African Americans were significantly less likely to die by 

suicide than individuals of any other race/ethnicity group. In African Americans with substance use 

disorder, no other variables were significantly associated with death from suicide. In non-African 

Americans (primarily white race), death from suicide was associated with having been admitted to 

an inpatient psychiatric ward in the 12 months prior to the suicide. In those without a substance use 

disorder, males had almost four times the rates of suicide compared to women.27 This study used 

a replication cohort to validate their findings. All factors identified in the derivation cohort also 

significantly discriminated suicides from non-suicides in the validation/replication cohort. 

Pfeiffer et al. used the same population of 887,859 Veterans with depression to evaluate other 

psychiatric diagnoses as potential risk factors for suicide. This study found that the odds of suicide 

were higher among patients with generalized anxiety disorder and anxiety disorder not otherwise 

specified, and those receiving anti-anxiety medication.32 Interestingly, PTSD was a predictive factor 

in this population and several other psychiatric diagnoses were not significantly associated with 

depression (social phobia, obsessive-compulsive disorder [OCD], all other anxiety disorders).

Zivin et al. used data from 807,694 Veterans (NARDEP data linked with VA Medicare data and 

NDI; 1,683 suicides over a 5.5 year period) and Cox proportional hazards regression to evaluate 

PTSD as a risk factor. Among depressed Veterans, PTSD was inversely associated with suicide in 

the older but not younger depressed Veterans (interaction term PTSD x age ≥ 65 years HR 0.66; 

95% CI, 0.44 to 0.99 versus [vs] PTSD x age 45-64 years HR 0.80; 95% CI, 0.58 to 1.01). Other 

significant predictors of suicide were white race, male gender, non-Hispanic ethnicity, history of 

substance abuse, younger age (18-44 years), non-service connectedness, and having a history of 

an inpatient stay for any psychiatric disorder in the previous 12 months.41 This study was rated 

unclear risk of bias because of lack of information regarding missing data, and lack of reporting 

about coding process and blinding of raters. 

Brenner et al. evaluated data from 7,850,472 Veterans being evaluated in the mental health 

system (49,626 suicides) with Cox proportional hazards regression models for time to suicide 
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adjusted for psychiatric comorbidities. In this population, 49,626 Veterans had traumatic brain 

injury (TBI), and 105 had TBI and suicide. To be eligible, Veterans had to have received care 

between FY 2001and 2006. Inpatient and outpatient notes were searched for a diagnosis of TBI. 

Data were linked to the NDI. They found that Veterans with any TBI were 1.55 more likely 

to die of suicide (HR 1.55; 95% CI, 1.24 to 1.92) compared to those without, after adjustment 

for age, gender, eight psychiatric diagnoses including substance use disorder, and Veteran 

Integrated Service Network. Patients with concussion or fracture were 1.98 times more likely 

to die of suicide; those with cerebral contusion or traumatic intracranial hemorrhage were 1.24 

more likely.22 This study was rated as having unclear risk of bias because of lack of information 

regarding missing data, lack of reporting about coding process and blinding of raters. 

Kaplan et al. assessed Veteran status and psychiatric diagnoses using data from US Veterans from 

the National Health Interview Survey data between 1986-94, linked ot the Multiple Casuse of Death 

file throug the NDI (1986-97, n=320,890 men followed for up to 12 years). This study demonstrated 

that Veterans in the US had increased risk of suicide regardless of whether they were associated 

with the VA. Risk factors for suicide risk among Veterans identified in this study include: white race 

(compared with non-white race), education level of >12 years (compared with <12 years), and having 

activity limitations. Interestingly, the number of chronic psychiatric conditions was not a significant 

predictor for this population (adjusted HR 0.41; 95% CI, 0.14 to 1.26).30 This study was rated as 

having unclear risk of bias because of lack of information regarding missing data.

Other medical diagnoses. Severe pain: Using data on 5,082 pateints (n=854 suicides and 4,228 

who did not die by suicide) from the 1999 Large Health Survey of Veterans (LHSV), VA EMRs 

and NDI. Ilgen et al. found that severe pain compared to moderate or less pain was associated 

with higher risk of death by suicide (HR 1.33; 95% CI, 1.15 to 1.54). Other predictors from 

multivariate models including pain were male gender, white race, smoker status, schizophrenia, 

bipolar disorder I or II, depression, other anxiety, diabetes, cerebrovascular disease and lower 

mental health functioning as measured by the Mental Component Summary (MCS).29

Seyfried et al. evaluated 294,952 (n=241 suicides) VA patients over age 60 with dementia drawn 

from national data.35 Variables associated with suicide included: white race (OR), depression 

but not other psychiatric diagnoses (OR 2.0, 95% CI, 1.5 to 2.9), history of inpatient psychiatric 

hospitalizations (OR 2.3, 95% CI, 1.5 to 3.5), and having filled prescriptions for either 

antidepressants or anxiolytics (OR 2.1, 95% CI, 1.6 to 2.8 for antidepressants; OR 2.0, 95% CI, 

1.5 to 2.7 for anxiolytics). In this population, admission to a nursing home was protective (OR 

0.3, 95% CI, 0.1 to 0.8). 

Health services factors. Hospital quality factors: Desai et al. evaluated suicide risk using data 

from 128 psychiatric inpatient units within US VA hospitals. They adjusted multivariate models 

for psychiatric diagnosis, age, race, gender, discharge to the community, distance to nearest VA 

medical center and year of discharge. Higher risk of suicide was predicted by shorter length of 

stay (<14 days, RR 1.41, p<0.04), time to readmission (>180 days, RR 0.55, p=0.0001and poor 

continuity of care following discharge (1 reference vs none, RR 1.59, p<0.03). Readmission 

within the six months following hospitalization was protective.24

Timing after treatment interventions: Valenstein et al. evaluated 887,859 Veterans with 

depression ( NARDEP merged with NDI data) and found that suicide events were highest in the 
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first 12 weeks following psychiatric hospitalizations compared to the second 12 weeks (RR 1.9; 

95% CI, 1.5 to 2.4), and higher in the 12 weeks following changes in antidepressant regimen 

(new antidepressant starts, adding another antidepressant, and dose changes) compared to the 

second 12 weeks (RR 1.8; 95% CI, 1.5 to 2.1).38

Retrospective case-control studies

In US Army soldiers, the adjusted odds for suicide were higher among those with a preceding 

hospitalization for alcohol, injury or mental disorder. Age and male gender were also associated 

with increased odds of suicide. Protective factors include: time in service (years), black race, less 

than college education, being married, and ranks as a warrant officer or commissioned officer.

20

Among Irish Defense Forces personnel, firearm suicide was associated with psychiatric illness or 

a history of deliberate self-harm, performing morning duty, and a recent medical downgrading.31

SUMMARY OF FINDINGS

Table 1: Summary of risk factors and associations with suicide attempts and suicides

Evidence for Suicide Attempt Evidence for Suicide

Demographic factors

Male gender (+) Ilgen 200927

(+) Ilgen 201029

(+) Zivin 200741

(NS) Seyfried 201135

Age (-) Tiet 200637 (older age protective) (+) Zivin 2007 (18-44 years)41

(NS) Seyfried 201135

White race (+) Ilgen 2009 (African American race 

protective)27

(+) Ilgen 201029

(+) Kaplan 200730

(+) Zivin 200741

(+) Seyfried 201135

Marital status (+) Thomsen 201136

(NS) Tiet 200637

(NS) Seyfried 201135

Education (NS) Thomsen 201136 (+) Kaplan 200730

Smoking (+) Ilgen 201029

Psychiatric factors

Psychiatric Conditions (+) Ilgen 2007 (composite variable)28

(+) Tiet 2006 (psychotic disorder, 

personality disorder)37

(+) Ilgen 2010 (men and women)25

(+) Ilgen 2010 (personality disorder and 

presence of more than 1 psychiatric 

diagnosis)26

(NS) Kaplan 2007 (number of chronic 

psychiatric conditions)30

PTSD (+) Belik 201019

(+) Brenner 201121

(+) Ilgen 2010 (men and women)25

(+) Ilgen 201026

(-) PTSD was protective in Zivin 200741

(-) PTSD was protective in Pfeiffer 200932

(NS) Seyfried 201135

Depression (+) Hartl 200514

(+) Belik 201019

(+) Tiet 200637

(+) Ilgen 201025

(+) Ilgen 201026

(+) Ilgen 201029

(NS) Pfeiffer 200932

(+) Seyfried 201135

Bipolar Disorder (+) Ilgen 2010 (men and women)25

(+) Pettit 2006 (very early onset bipolar 

disorder)42

(+) Ilgen 201026

(+) Ilgen 201029
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Evidence for Suicide Attempt Evidence for Suicide

Anxiety (+) Tiet 200637 (+) Ilgen 2010(men and women)25

(+) Ilgen 201026

(+) Ilgen 201029

(+/NS) Pfeiffer 2009 (some but not all 

anxiety conditions)32

(NS) Seyfried 2011 (but having an 

anxiolytic prescription was associated 

with suicide)35

Schizophrenia (+) Ilgen 2010 (men and women)25

(+) Ilgen 201026

(+) Ilgen 201029

(NS) Seyfried 201135

Prior suicide attempt (+) Hartl 200514

(+) Thomsen 201136

Social phobia (+) Belik 201019

Alcohol abuse (+) Ilgen 200728

(+) Belik 201019

(NS) Tiet 200637

(+) Ilgen 2010 (men and women)25

Substance abuse (+) Ilgen 2007 (cocaine)28

(NS) Tiet 200637 (drug abuse or 

dependence)

(+) Ilgen 2010 (men and women)25

(+) Zivin 200741

History of inpatient psychiatric 

hospitalization

(+) Seyfried 201135

(+) Zivin 2007 (within last 12 months)41

Negative life events (+) Pettit 2006 (among those with very 

early onset MDD, very early onset 

anxiety and no history of very early onset 

psychopathology)42

Trauma and military factors

Traumatic Brain Injury (TBI) (NS) Brenner 201121 (+) Brenner 201122

Witnessing man-made disaster (+) Belik 2009 (women only)18

Being a victim of child abuse or 

other abuse

(+) Belik 2009 (women only)18

(+) Cox 2011 (sexual abuse and other 

trauma)23

Witnessing domestic violence (+) Belik 2009 (women only)18

(+) Cox 2011 (as a child)23

Being stalked (+) Belik 200918

Being mugged, being kidnapped (+) Belik 2009 (men only)18

Having purposely injured or killed (+) Belik 2009 (men only)18

Toxic chemical exposure (+) Belik 2009 (men only)18

Life-threatening illness (+) Belik 2009 (men only)18

Sexual abuse (+) Tiet 2006 (past 30 days or lifetime)37

(+) Cox (childhood)

(+) Belik 2009 (sexual assault or rape)18

Physical abuse in past 30 days (+) Tiet 2006 (physical abuse in past 30 

days)37

(NS) Tiet 2006 (lifetime physical abuse)37

Combat deployment (NS) Thomsen 201136

Traumatic event happened to 

another

(+) Belik 200918

Other trauma (+) Belik 2009 (men only)18

Being a civilian in a place where 

there was ongoing terror of 

civilians for political, ethnic, 

religious or other reasons)

(+) Belik 200918

Non-service connected status for 

Veterans

(+) Zivin 200741
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Evidence for Suicide Attempt Evidence for Suicide

VA association (vs non-VA 

associated Veterans)

(NS) Kaplan 2007 (all Veterans had 

higher risk of suicide regardless of VA 

affiliation)30

Other

Diabetes (+) Ilgen 201029

Cerebrovascular disease (+) Ilgen 201029

Lower mental health functioning 

(MCS-12 score)

(+) Ilgen 201029

Admission to nursing home (-) protective in Seyfried 201135

Severe pain (+) Ilgen 201029

Activity limitations (+) Kaplan 200730

(+) positively associated with increase in suicide outcome (i.e., risk factor)

(-) negatively associated with increase in suicide outcomes (i.e., protective factor)

(NS) evaluated and found not to be significantly associated with the suicide outcome

Table 2: Summary of Risk Studies

Author, Year

Study Design/ 

Analysis Population Outcome

Risk of Bias 

and main flaws

Belik 200918 Crosssectional

8,441 Canadian military personnel, 

active military within 6 months

Self-reported suicide 

attempt

Unclear 

Belik 201019 Crosssectional

8,441 Canadian military personnel, 

active military within 6 months

Self-reported suicide 

attempt

Unclear 

Bell 201020 Case control 1,873 identified suicides from 

Army.

Suicide Unclear 

Brenner 201121

(“Posttraumatic...”)

Case-control Veterans receiving mental health 

services

EMR note of suicide 

attempt

Unclear

Brenner 201122

(“Suicide...”)

Longitudinal Veterans receiving mental health 

services

Suicide by ICD-10 Unclear

Cox 201123 Crosssectional 

656 men and women admitted 

to the psychiatry unit of a large 

US Army for suicidal thoughts or 

behaviors

Admission for suicide 

attempt

Unclear 

Desai 200524 Longitudinal 121,933 patients discharged from 

US VA hospital inpatient psychiatry 

wards with major affective 

disorder, bipolar disorder, PTSD or 

schizophrenia (481 suicides)

Suicide identified by ICD9/10 and NDI, 1 year after 

inpatient discharge

Unclear

Hartl 200514 Longitudinal 630 male Veterans with PTSD Self-reported suicide 

attempt after discharge 

from the inpatient unit

Unclear 

Ilgen 200728 Longitudinal 8,807 Veterans enrolled in 

substance abuse programs

Self-reported suicide 

attempt within 30 days 

prior to the 1 year follow-up 

assessment

Unclear 

Ilgen 200927 Longitudinal 589,825 VA patients treated for 

depression

Suicide confirmed by NDI Unclear 

Ilgen 201025

(“Psychiatric 

Diagnoses...”)

Longitudinal All US Veterans (3,291,891) who 

used VA services during Fiscal 

Year (FY) 1999 and were alive at 

the start of FY 2000

Suicide confirmed by NDI Unclear 

Ilgen 201029

(“Severe Pain...”)

Longitudinal 260,254 US Veterans who 

responded to the 1999 LHSV

Suicide confirmed by NDI Unclear 

Ilgen 201026

(“Violent and 

Nonviolent 

Suicide...”)

Longitudinal 5,082 US Veterans who were alive 

at the beginning of FY 2002 (854 

suicides and 4,228 who did not die 

by suicide)

Suicide confirmed by NDI Unclear 
29

Suicide Risk Factors and Risk Assessment Tools:

A Systematic Review Evidence-based Synthesis Program

Author, Year

Study Design/ 

Analysis Population Outcome

Risk of Bias 

and main flaws

Kaplan 200730 Longitudinal 104,026 male US Veterans Suicide confirmed by NDI Unclear

Mahon 200531 Case control 732 death in Irish Defense Forces Suicide by military files and 

proceedings of the Courts 

of Inquiry

Unclear 

Pettit 200642 Crosssectional

298 military-based young adults at 

entry to treatment for suicidality

Self-report suicide attempt Unclear

Pfeiffer 200932 Longitudinal 887,889 US Veterans with 

depression

Suicides from NDI and 

ICD-10

Unclear

Pinder 201133 Crosssectional

821 personnel who participated 

in the King’s Centre for Military 

Health Research military health 

study (UK Armed Forces)

Self-report of lifetime 

suicide attempt or selfharm

High

Roy 201134 Case control 40 US Veterans with prior 

substance abuse, currently 

abstinent

Self-report suicide attempt High

Seyfried 201135 Longitudinal 294,952 US Veterans Suicide by NDI and ICD-10 Low

Thomsen 201136 Crosssectional

2116 active duty military personnel 

serving at US Marine Corps 

installations

Self-report of suicide 

attempt

Unclear

Tiet 200637 Crosssectional

34,245 substance abuse patients 

from 150 US VA facilities

Self-report of suicide 

attempt in past 30 days 

by ASI

Unclear

Valenstein 200938 Longitudinal 887,859 US Veterans with 

depression

Suicide using NDI Unclear

Yerevanian 2007 - 

Part 240

Longitudinal 405 Veterans with bipolar disorder Suicidal behavior assessed 

by chart review

High

Yerevanian 2007 - 

Part 339

Longitudinal 406 Veterans with bipolar disorder Suicidal behavior assessed 

by chart review

High

Zivin 200741 Longitudinal 807,694 US Veterans with 

depression

Suicide by NDI Unclear
30

Suicide Risk Factors and Risk Assessment Tools:

A Systematic Review Evidence-based Synthesis Program

SUMMARY AND DISCUSSION

SUMMARY OF EVIDENCE BY KEY QUESTION

We identified 14 good quality systematic reviews (reported in 16 publications) of risk assessment 

tools and risk factors, as well as five primary studies of risk assessment tools and 25 primary studies 

of risk factors. Risk assessment tools and risk factor primary studies were performed in Veteran and 

military populations. We examined studies from a limited time period (2005 through November 2011) 

due to the publication of two systematic reviews with similar scope published in 2004 and 2005.4, 5

We conducted this report in order to gather the most up-to-date information on suicide prevention, 

with a particular emphasis on Veterans and members of the military. To do this, we examined 

systematic reviews conducted since the Gaynes and Mann reports,4, 5 as well as primary articles 

focused on Veterans and members of the military. In all studies, we considered quality of design 

and implementation in order to best assess the strength of evidence provided. Though some studies 

may not be affected by certain design or implementation flaws, many studies related to suicide are 

complex and difficult to implement in a manner free of risk of bias. For example, studies examining 

suicide as an outcome may not have a significantly increased risk of bias if outcome assessors are 

not blinded; this is because suicide is a relatively objective outcome to assess. Suicide behavior and 

other aspects of suicidal self-directed violence, on the other hand, though they may appear objective, 

often require subjective decision-making when assessed by methods such as chart review due to 

variation in documentation and in definition of the outcome. Likewise, when risk factors are assessed 

by chart review, the same potential for bias exists if assessors are not blinded to the suicide outcome 

status. These quality considerations were reported with the data obtained from all included studies.

Systematic Reviews

Though we found 34 systematic reviews conducted since 2005, none of the 14 high quality 

reviews provided sufficient evidence for suicide risk assessment tools and suicide risk factors 

due to the variations in the scope of the reviews. We further examined all primary studies cited in 

these reviews if they met our inclusion criteria, and we included these studies in our synthesis of 

primary studies, listed by key question below.

Key Question #1. What assessment tools are effective for assessing risk of 

engaging in suicidal self-directed violence in Veteran and military populations?

Evaluation of the effectiveness of risk assessment tools is lacking, both among existing reviews 

with a more broad focus than this report, and among the studies examined in this report which focus 

on Veterans and members of the military. The three existing systematic reviews covering this topic 

all came to similar conclusions, noting the dearth of evidence from prospective studies examining 

associations among suicide prevention assessment tools and suicidal self-directed violence outcomes. 

Two non-systematic reviews on the topic came to similar conclusions. The Brown report cites 

numerous measures that have demonstrated adequate internal reliability and concurrent validity,11

though highlights the Scale for Suicidal Ideation and the Beck Hopelessness Scale as two of only very 

few measures that have shown associations with death by suicide. 

We examined the best available evidence from primary studies related to Veterans and members 

of the military. Among the five primary studies that met our inclusion criteria, three are of limited 
31

Suicide Risk Factors and Risk Assessment Tools:

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quality. There were no studies identified that evaluated whether a risk assessment tool can accurately 

reclassify Veterans and military personnel from low risk of suicide to higher risk. This leads to 

an inconclusive rating for the overall strength of evidence regarding assessment tools for suicide. 

Evidence of accurate reclassification would be necessary to increase this overall assessment of 

strength of evidence for research investigating suicide risk assessment tools. 

Though this relatively small number of studies provides insufficient and low strength evidence for the 

assessment of suicide risk factors with the tools that were investigated, certain aspects of the findings 

warrant further discussion. Two of the studies investigated assessment tools commonly used in VA 

settings: the PAI13 and the BDI-II,14 whereas the other three studies investigated tools not commonly 

used in VA settings15, 16 or no longer commonly used in VA settings.17 Of these latter three studies of 

assessment tools less common to VA settings, the IPS is lengthy and the results are seriously called 

into question due to the method of assessment and group comparison (one group was assessed by 

estimating history post-mortem and compared to responses from a living comparison group). The 

study by Hendin et al. investigated the ASQ, a brief screening tool designed to assess risk of suicide.15

Though the sample was relatively small (n=283) and the study was rated as having an unclear risk of 

bias, preliminarily positive results and ease of implementation suggest that this tool warrants further 

research investigating potential for use and predictive power in a validation sample of Veterans or 

members of the military. Finally, the study by Tiet et al. investigating the ASI is useful for gathering 

information on a large population of Veterans.17 Although this is only one study, the data derive from 

an entire population of Veterans (34,000) who were administered the ASI, lending support to the 

strength of evidence for this measure; however, because this lengthy structured interview is no longer 

routinely used in VA settings, the utility of the ASI as a suicide risk assessment tool is greatly limited.

Of the tools commonly used in the VA, the following describes considerations for implementation 

as suicide risk assessment tools: the PAI, though commonly used in VAs and other settings as part 

of lengthy psychological assessments, is difficult to administer without training, time, and electronic 

scoring software; however, this tool could potentially be used to design new, brief assessment 

measures based on the content of the subscales and items predictive of suicidal self-directed violence 

as preliminary evidence from this one study on a small sample of Veterans who had TBIs. Finally, 

the BDI-II is a brief, easy to administer, easy to score depression screening tool that is commonly 

used in VA settings. This tool was examined in conjunction with information on participants’ 

previous suicide attempt history. Hartl et al. report promising exploratory model results predicting 

suicide attempts, though note that in a validation cohort, the model obtained a significantly lower 

sensitivity score.14 Therefore, though many aspects of the research on the BDI-II are promising, 

further research is needed to establishing acceptable predictive power before this tool should be 

considered for widespread adoption. An adapted and shortened version of the PAI subscales and the 

BDI-II could both potentially be used in primary care settings, though given length and administration 

considerations, the BDI-II may be more easily implemented in such settings.

Key Question #2. In addition to the risk factors included by current assessment 

tools, what other risk factors predict suicidal self-directed violence in Veteran and 

military populations?

Studies of risk factors related to suicide indicate that psychiatric conditions are associated with 

suicide, especially depression and anxiety. Evidence is conflicting about whether PTSD is an 

independent risk factor in all or just some populations. 
32

Suicide Risk Factors and Risk Assessment Tools:

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We identified 26 studies meeting inclusion criteria that addressed risk factors for suicidal self-directed violence in Veteran and military populations. All evaluated risk factors after accounting for variance associated with other previously established risk factors. Four of these were determined to have 

unacceptably high risk of bias and, therefore, are not discussed further. The remaining 22 studies 

were all determined to have unclear risk of bias. No studies had low risk of bias. Limitations in study 

design and analysis that led to a rating of high or unclear risk of bias included: assessment of suicidal 

behavior by chart review only, a method that is biased by provider assessment and documentation (or 

lack of assessment and documentation) about the behavior; lack of assessor blinding when utilizing 

chart review of assessment of risk factors; use of ICD-9 chart diagnoses for determination of risk (as 

opposed to a clinician administered tool or history); recruitment methods that reflect a non-representative population; failure to report on the handling of missing data; among others. 

Suicide attempts

Nine studies of suicide attempts used longitudinal, cross-sectional and case-control analyses 

to assess risk factors (two not discussed further because of high risk of bias). Suicide attempt 

outcomes were often self-report and occasionally objectively documented (by clinician referral or 

hospital admission). Factors that were significant predictors of suicide attempts were: prior suicide 

attempt and depressive symptoms as measured by the BDI,14 suicide or psychiatric symptoms (a 

composite of variables based on multiple aspects of suicidality from the ASI), alcohol and cocaine 

abuse.28 Protective factors included: involvement with the criminal justice system and number of 

days participating in substance abuse treatment program. In a study of Canadian military personnel 

having purposely injured or killed, toxic chemical exposure, life-threatening illness, and being a 

civilian in religious terror (being a civilian in a place where there was ongoing terror of civilians for 

political, ethnic, religious or other reasons) were significant predictors of suicide attempts among 

men.18, 19 In this study, women differed from men as to which variables predicated suicide attempt; 

risk factors for women tended to classified as “traumatic.”

Death by suicide 

Risk factors for death by suicide were assessed in 15 studies (two not discussed further because 

of high risk of bias; Tables 1 and 2). Outcome determination used NDI data linked with other 

types of registries and hospital records. Risk factors that were associated with death by suicide 

in more than one study include: white race, bipolar disorder and substance abuse. Several risk 

factors were only significant (or reported) in one study of death by suicide: education, alcohol 

abuse, TBI, diabetes, cerebrovascular disease, lower MCS-12 scores reflective of mental health 

functioning, severe pain and activity limitations. Others had mixed results, with some but not 

other studies finding significant association with suicide: male gender, age, anxiety, number of 

psychiatric conditions, PTSD, depression, anxiety, schizophrenia, history of inpatient psychiatric 

hospitalization, alcohol abuse and non-service connected Veteran status. Admission to a nursing 

home was found to be protective in one study. 

Combining risk factors for suicide attempts and death by suicide may give a more thorough 

picture of suicide risk factors; however, doing so with the studies reviewed here does not shed 

substantially greater light. For PTSD, depression and psychiatric conditions, including the data 

from suicide attempts (in addition to the data from suicides) support these variables as risk 

factors for suicide. Many other risk factors remain evaluated in only one study.
33

Suicide Risk Factors and Risk Assessment Tools:

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LIMITATIONS

The highest quality evidence for risk assessment tools and risk factors derives from studies that 

evaluate tools or variables in a population and then follow that population for the development 

of the outcome. New risk factors must account for known risk factors so that conclusions can be 

drawn about whether the risk factors act independently or through other known mechanisms. Thus, 

studies of risk instruments have the potential to be limited by their study design (cross-sectional 

rather than prospective design), method of assessment of risk factors (clinician-generated diagnosis 

of depression versus a diagnosis of depression based on administrative codes or self-report 

symptom measure), and the lack of adjustment for confounding variables. For this review, we 

excluded many articles because they did not adjust for appropriate confounders. Careful attention to 

collection and adjustment for known confounders will be important for any research going forward.

We limited our search to studies on Veterans and/or members of the military. Though we chose 

to apply this limitation for reasons of improved generalizability given the unique risk factors 

experienced by the populations of interest, it is likely that important lessons could be learned 

from studies utilizing non-Veteran and non-military populations, and findings from such 

reports (e.g., the Mann, Gaynes, and NICE reports summarized in this current review)4-6 should 

be considered in spite of their broader focus. Despite this restriction to Veteran and military 

populations, the included studies in this current report remained sufficiently heterogeneous to 

preclude meaningful quantitative synthesis and comparison. 

Studies varied in terms of population (Veterans with mental health disorders or substance use 

disorders, including those with recent/current psychiatric admission versus active military), settings 

and risk factors assessments. Inherent to this type of research is the fact that risk factors differ between 

populations according to the prevalence of underlying conditions in that population. Thus, in cases 

where there is discrepancy about whether a certain predictive factor conveys risk, protection or is 

neutral (as is the case with PTSD), population differences may be part of the explanation. 

Some of the factors determined by these studies are specific to the populations studied. For 

instance, Ilgen et al. found that number of treatment days was an important protective factor in 

their study of suicide after admission to inpatient substance use disorders program.28 Clearly, 

this protective factor is not generalizable to populations of Veterans that have not been admitted 

to an inpatient treatment unit. There may be other risk factors that differ substantively between 

populations for other less readily apparent reasons.

Another potential limitation of this literature is the use of suicide attempts as an outcome. This 

outcome has high potential for misclassification bias. That is, assessment of suicide attempts 

relies on accurate assessment and documentation by the provider as well as accurate reporting 

by the patient. There is potential for under- and over-reporting in both instances. For this 

reason, documented suicide attempts that result in hospitalization or ER visits are more rigorous 

outcomes than self-reported suicide attempts.

Overall, the literature demonstrates a large group of associated risk factors that have been evaluated 

in various heterogeneous populations within Veteran and military groups. There have been few 

studies of active military personnel and women. These factors limit our ability to draw strong 

conclusions about risk factors that predict suicide for the entire Veteran and military population.
34

Suicide Risk Factors and Risk Assessment Tools:

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RECOMMENDATIONS FOR FUTURE RESEARCH

Research on suicide is inherently difficult because of the very low base rate occurrence of both 

suicide and suicidal self-directed violence in general populations. Therefore, future studies 

of both risk factors and risk assessment tools should utilize adequate sample sizes to achieve 

sufficient power to detect changes in rates of suicide and suicidal self-directed violence. 

Future research needs to focus on critical evidence gaps. There is a striking lack of assessment 

tool evaluation research among Veteran and military populations. Several risk instruments 

have been developed and tested in other populations: the Suicide Assessment Checklist, the 

Manchester Self-Harm Rule, the Suicide Probability Scale, the Suicide Ideation Questionnaire, 

the Suicide Risk Assessment Scale, and the Beck Scale for Suicide Ideation, among others.110-117

A reasonable next step would be to test some of these instruments in Veteran and military 

populations. Research would ideally be prospective and involve adequately blinded assessment 

techniques to reduce potential bias. Moving forward, it will also be important for studies of risk 

assessment tools to evaluate how well these tools discriminate people who will go on to attempt 

or die by suicide from those who do not. 

VA medical centers and the military already use assessment tools to screen for mental health 

disorders associated with suicide (e.g., depression, substance use disorders, and PTSD), as 

well as measures designed to screen for suicidal ideation and intent. These screening tools 

are implemented among large, general populations of Veterans and members of the military, 

and are often scored and recorded in EMRs. We did not find any articles examining whether 

or not these measures predicted suicidal self-directed violence, though some information was 

available related to the Patient Health Questionnaire-9 (PHQ-9), a measure developed to screen 

for depression and currently broadly implemented in VA settings. One item on the PHQ-9 is 

designed to assess suicidality, though studies have validated this item for suicidal ideation only, 

as reported in follow-up clinical interviews, not suicide.118, 119 Though this PHQ-9 item has 

been associated with suicidal ideation, controversy remains about whether it is an appropriate 

assessment tool for suicide. Critics note the vague and multi-component nature of the PHQ-9 

suicidality item,120 while proponents counter that the suicidality item should necessarily prompt 

further questioning that would lead to additional (adequate) assessment of suicidal ideation 

and plans.120 Future research should investigate the predictive power of both the PHQ-9 and 

other commonly used tools implemented in VA and military primary care settings. If any such 

assessment tools are predictive of suicidal self-directed violence, researchers should establish 

cutoff scores to classify suicide risk.

Another notable gap in the literature is related to the relative paucity of research conducted with 

members of the military compared to studies focusing on Veterans. One reason that there are 

several studies using VA data is because the VA has a comprehensive clinical data source that 

is available for linkage with other national databases (NDI, etc.). If similar data were available 

for the active military population (perhaps from the military suicide event reporting database, 

DODSER) and/or the full complement of Veterans and military, then this could enable strong 

research to be completed in the military population. 

An interesting question is that of coordination of care transitions and the role that the system 

(military, VAMC or hospital, primary care provider) plays in helping to prevent suicide. Desai 
35

Suicide Risk Factors and Risk Assessment Tools:

A Systematic Review Evidence-based Synthesis Program

et al. suggest that improved access to care in the first six months after psychiatric hospitalization 

is beneficial for preventing suicide attempts.24 Therefore, researchers might think broadly about 

settings in which suicide risk assessment tools are applied, such as during or immediately 

following inpatient hospitalization. Studies to test risk assessment tools that predict suicide 

attempts across multiple settings such as primary care physician visits, post-discharge (through a 

post-discharge follow-up phone call or visit), etc. could be valuable.

Future studies about risk factors need to address and account for known risk factors carefully. 

Future research should focus on determining factors that provide additional predictive power 

above and beyond known risk factors such as previous suicide attempt history, depression and 

other mental health diagnoses, and substance use disorders. Ideally, this research would be 

prospective, involve adequately blinded assessment techniques to reduce potential bias, and 

utilize adequate sample sizes to achieve sufficient power given the very low base rate occurrence 

of both suicide and suicidal self-directed violence. Given the unique risk factors often faced by 

Veterans and members of the military (e.g., combat-related PTSD, TBI, etc.), these emerging risk 

factors should be a particular emphasis of future research. Research in this area may also move 

towards an examination of warning signs, factors that are thought to signify more immediate 

state of risk, as opposed traditional risk factors that reflect an overall heightened state of risk. 

Identification of short-term warning signs could identify certain populations who need more 

immediate intervention.

Future research is necessary to better understand differences in risk factors among populations. 

In particular, the differences between risk factors for suicide among men and women are 

understudied. Despite the fact that the majority of suicides in the Veteran population occur 

in men, women have different risk factors predictive of suicide and could need different 

interventions in order to reduce suicide rates. 

CONCLUSIONS

KQ# Key Question Type of 

Evidence

Quality of 

Evidence Comments

1 What assessment tools 

are effective for assessing 

risk of engaging in suicidal 

self-directed violence 

in Veteran and military 

populations?

5 studies testing 

validated 

measures 

in Veteran 

or military 

populations 

2 studies had 

unclear risk of 

bias; 3 studies 

had high risk of 

bias

Insufficient evidence overall to recommend 

screening with these risk assessment tools 

based on this evidence. Future research is 

warranted, particularly for risk assessment 

instruments that are already in use within 

the VA system.

2 In addition to the risk 

factors included by current 

assessment tools, what 

other risk factors predict 

suicidal self-directed 

violence in Veteran and 

military populations?

25 studies of 

risk factors for 

suicide attempts 

and suicides 

among Veteran 

and military 

populations

21 studies with 

unclear risk 

of bias and 4 

studies with high 

risk of bias

Insufficient evidence overall. 

Strongest evidence exists for risk factors 

that have been previously identified (white 

race, male gender, psychiatric disorders, 

substance use disorders, and trauma). 

More research is warranted to understand 

emerging risk factors in younger Veteran 

and military populations.
36

Suicide Risk Factors and Risk Assessment Tools:

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