Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program

Systematic Review of 

Suicide Prevention in 

Veterans 

November 2015

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, MD, MCR, Director

Investigators:

Principal Investigator: 

Heidi D. Nelson, MD, MPH

Contributing Investigators: 

Lauren Denneson, PhD

Allison Low, BA

Brian W. Bauer, BA

Maya O’Neil, PhD

Devan Kansagara, MD, MCR

Alan R. Teo, MD, MS

NOTE: This publication is for internal use of the Department of 

Veterans Affairs and should not be distributed outside the agency.
Benefits and Harms of the Mediterranean Diet Evidence-based Synthesis Program

Compared to Other Diets

i 

PREFACE

The VA Evidence-based Synthesis Program (ESP) was established in 2007 to provide timely and 

accurate syntheses of targeted healthcare topics of particular importance to clinicians, managers, and 

policymakers as they work to improve the health and healthcare of Veterans. QUERI provides funding 

for four ESP Centers, and each Center has an active University affiliation. Center Directors are 

recognized leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based 

Practice Centers. The ESP is governed by a Steering Committee comprised of participants from VHA 

Policy, Program, and Operations Offices, VISN leadership, field-based investigators, and others as 

designated appropriate by QUERI/HSR&D.

The ESP Centers generate evidence syntheses on important clinical practice topics. These reports help: 

Develop clinical policies informed by evidence;

Implement 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.

The ESP disseminates these reports throughout VA and in the published literature; some evidence 

syntheses have informed the clinical guidelines of large professional organizations. 

The ESP Coordinating Center (ESP CC), located in Portland, Oregon, was created in 2009 to expand the 

capacity of QUERI/HSR&D and is charged with oversight of national ESP program operations, program 

development and evaluation, and dissemination efforts. The ESP CC establishes standard operating 

procedures for the production of evidence synthesis reports; facilitates a national topic nomination, 

prioritization, and selection process; manages the research portfolio of each Center; facilitates editorial 

review processes; ensures methodological consistency and quality of products; produces “rapid response 

evidence briefs” at the request of VHA senior leadership; collaborates with HSR&D Center for 

Information Dissemination and Education Resources (CIDER) to develop a national dissemination 

strategy for all ESP products; and interfaces with stakeholders to effectively engage the program.

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

Manager, at Nicole.Floyd@va.gov. 

Recommended citation: Nelson H, Denneson L, Low A, Bauer B, O'Neil M, Kansagara D, Teo A. 

Systematic Review of Suicide Prevention in Veterans. VA ESP Project #05-225; 2015. 

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at 

the Portland VA Health Care System, 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 (eg, 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. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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TABLE OF CONTENTS

EXECUTIVE SUMMARY .......................................................................................................... 1

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

Methods....................................................................................................................................... 2

Data Sources and Searches ..................................................................................................... 2

Study Selection ....................................................................................................................... 2

Data Abstraction and Quality Assessment .............................................................................. 2

Data Synthesis and Analysis ................................................................................................... 3

Results ......................................................................................................................................... 3

Results of Literature Search .................................................................................................... 3

Summary of Results for Key Questions.................................................................................. 3

Discussion ................................................................................................................................... 6

Key Findings and Strength of Evidence ................................................................................. 6

Applicability ........................................................................................................................... 7

Conclusions ............................................................................................................................. 7

Abbreviations Table .................................................................................................................... 8

INTRODUCTION......................................................................................................................... 1

Purpose ........................................................................................................................................ 1

Background ................................................................................................................................. 1

Current Practices ......................................................................................................................... 1

METHODS .................................................................................................................................... 3

Topic Development ..................................................................................................................... 3

Search Strategy ........................................................................................................................... 4

Study Selection ........................................................................................................................... 5

Data Abstraction ......................................................................................................................... 6

Quality Assessment ..................................................................................................................... 6

Data Synthesis ............................................................................................................................. 6

Rating the Body of Evidence ...................................................................................................... 7

RESULTS ...................................................................................................................................... 8

Search Results ............................................................................................................................. 8

Key Question 1 ........................................................................................................................... 9
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Key Question 2 ......................................................................................................................... 34

Key Question 3 ......................................................................................................................... 48

Methods to Identify Suicide Risk ......................................................................................... 48

Healthcare Service Interventions for Suicide Prevention ..................................................... 53

SUMMARY AND DISCUSSION .............................................................................................. 59

Summary of Evidence by Key Question ................................................................................... 59

Key Question 1 ..................................................................................................................... 59

Key Question 2 ..................................................................................................................... 60

Limitations ................................................................................................................................ 62

Study Quality ........................................................................................................................ 62

Heterogeneity ........................................................................................................................ 62

Applicability of Findings to the VA Population ................................................................... 62

Conclusions ............................................................................................................................... 62

REFERENCES ............................................................................................................................ 66

TABLES

Table 1. Measures of Test Accuracy........................................................................................... 5

Table 2. Previous Systematic Reviews of Methods to Identify Individuals at Risk for Suicide 

and Other Suicidal Self-Directed Violence ............................................................................... 10

Table 3. Studies of the Accuracy of Methods to Identify Individuals at Risk for Suicide and 

Other Suicidal Self-directed Violence ...................................................................................... 18

Table 4. Measures Used as Predictors or Outcomes in Studies of Methods to Identify 

Individuals at Risk for Suicide and Other Suicidal Self-directed Violence Included in the 

Systematic Review .................................................................................................................... 24

Table 5. Quality Ratings of Studies of Methods to Identify Individuals at Risk for Suicide and 

Other Suicidal Self-directed Violence* .................................................................................... 27

Table 6. Previous Systematic Reviews of the Efficacy or Effectiveness of Suicide Prevention 

Interventions in Reducing Suicide and Other Suicidal Self-directed Violence ........................ 35

Table 7. Studies of Population-level Healthcare Service Interventions for Suicide Prevention

................................................................................................................................................... 39

Table 8. Randomized Controlled Trials of Individual-level Healthcare Service Interventions 

for Suicide Prevention............................................................................................................... 43

Table 9. Quality Ratings of Randomized Controlled Trials of Healthcare Service Interventions 

for Suicide Prevention*............................................................................................................. 45

Table 10. Ongoing Studies of Methods to Identify Suicide Risk* ........................................... 51
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 11. Ongoing Studies of Healthcare Service Interventions for Suicide Prevention* ....... 55

Table 12. Summary of Evidence ............................................................................................... 64

Table 13. Strength of Evidence Ratings for Studies of the Efficacy/Effectiveness and Adverse 

Effects of Healthcare Service Interventions for Suicide Prevention ........................................ 65

FIGURES

Figure 1. Analytic Framework .................................................................................................... 3

Figure 2. Literature Flow Chart .................................................................................................. 8

Figure 3. Summary of Studies of Methods to Identify Suicide Risk Reporting Sensitivity and 

Specificity ................................................................................................................................. 13

Figure 4. Summary of Studies of Methods to Identify Suicide Risk Reporting Area Under the 

Receiver-Operator Characteristic Curve (AUC) ....................................................................... 14

APPENDIX A. SEARCH STRATEGIES ................................................................................... 80

APPENDIX B. STUDY SELECTION ........................................................................................ 84

APPENDIX C. CRITERIA USED IN QUALITY ASSESSMENT ........................................... 86

APPENDIX D. PEER REVIEW COMMENTS/AUTHOR RESPONSES ................................. 91

APPENDIX E. EXCLUDED REFERENCES........................................................................... 104
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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EXECUTIVE SUMMARY 

INTRODUCTION 

This systematic review updates evidence on the accuracy of methods to identify individuals at 

increased risk for suicide, and the efficacy/effectiveness and adverse effects of healthcare service

interventions in reducing suicide and other suicidal self-directed violence. Important areas of 

ongoing research and current evidence gaps on suicide prevention are also addressed. This report 

includes studies relevant to healthcare services provided to Veterans and military personnel in 

the United States (US), and updates 3 previous Department of Veterans Affairs (VA) Evidencebased Synthesis Program (ESP) reviews on these topics. 

Veterans and military personnel represent 20% of all known suicides in the US. Rates of suicide 

increased during the wars in Afghanistan and Iraq, and between 2000 and 2010, the suicide rate 

among Veterans rose higher than the rate among civilians. Female Veterans are at especially 

high risk relative to other women. These trends have led to new initiatives within the VA and 

military to address suicide prevention. 

During the year prior to suicide, an estimated 77% of individuals make contact with primary care 

and 32% with mental health care clinicians, providing opportunities for suicide risk assessment 

and intervention. However, screening for suicide risk in general medical practice is not part of 

standard care in the US. Efforts to prevent suicide in individuals at high risk, such as those with 

recent suicide attempts, generally include treatment of underlying conditions and psychotherapy. 

In addition to individual-level approaches to suicide prevention, initiatives have been 

implemented at organizational, health system, and community levels. However, despite the 

existence of many types of services, very few studies demonstrating their efficacy and 

effectiveness have been published. As a result, their influence on suicide prevention remains 

unclear.

This systematic review is an update of previous VA ESP reviews that addresses the following 

key questions: 

Key Question 1 

A) What are the accuracy and adverse effects of methods to identify Veterans and military 

personnel at increased risk for suicide and other suicidal self-directed violence? 

B) Does accuracy and adverse effects vary by settings, delivery modes, targeted populations, or 

other factors?

Key Question 2 

What are the efficacy/effectiveness and adverse effects of suicide prevention interventions in 

reducing rates of suicide and other suicidal self-directed violence in Veterans and military 

personnel? Interventions include healthcare services directed towards: 

A) Populations (eg, hotlines, outreach programs). 

B) Individuals (eg, case management, follow-up). 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Key Question 3 

What are important areas of ongoing research and current evidence gaps in research on suicide 

prevention in Veterans and military personnel, and how could they be addressed by future 

research?

METHODS 

Data Sources and Searches 

Electronic database searches were conducted for MEDLINE, PubMed, PsycINFO, SocINDEX, 

Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic 

Reviews (January 1, 2008 to September 11, 2015). A search of the grey literature was conducted 

on July 16, 2015. In addition, citations from reference lists of relevant primary studies, reviews, 

and conference proceedings, and from clinical and research experts were reviewed for inclusion. 

Study Selection 

Eligible English-language studies included populations of Veterans, military personnel, and 

demographically comparable non-Veteran/military adults aged 18 and older from the US, United 

Kingdom (UK), Canada, New Zealand, and Australia, consistent with inclusion criteria of the 

previous VA ESP reviews. 

For Key Question 1, included studies evaluated the diagnostic accuracy and adverse effects of 

methods to assess risk for suicide and other suicidal self-directed violence, including 

instruments, checklists, and other approaches appropriate for clinical settings. For Key Question 

2, studies of the efficacy or effectiveness of interventions were included that were specifically 

designed to prevent suicide and other suicidal self-directed violence and evaluated in randomized 

controlled trials (RCTs), observational studies with comparison groups, and systematic reviews 

with these study designs. Interventions included healthcare services directed towards populations 

or individuals that are clinically relevant to medical practice in the US. Studies of interventions 

that primarily treat co-existing conditions and studies of pharmacotherapy were outside the scope 

of this update. Key Question 3 is based on evidence gaps identified from the synthesis of studies 

addressing Key Questions 1 and 2. Consequently, studies included for Key Question 3 were 

identified from the searches for Key Questions 1 and 2. In addition, ongoing studies were 

selected from websites and other sources identified by the search of grey literature based on their 

relevance to the key questions.

Data Abstraction and Quality Assessment 

Data from included studies were abstracted into a database by one reviewer and over-read for 

accuracy by a second reviewer. Abstracted information included study design, setting, 

population, methodology, and results. Two reviewers independently assessed the risk of bias of 

included studies using pre-specified criteria, and each study was given an overall summary 

assessment of low, high, or unclear risk of bias. Disagreements were resolved through consensus 

using a third reviewer. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Data Synthesis and Analysis 

Conclusions are based on qualitative synthesis of the findings of recently published studies as 

well as relevant studies from the previous VA ESP reviews. The overall strength of evidence was 

determined using a method developed for the Agency for Healthcare Research and Quality’s 

(AHRQ) Evidence-based Practice Centers (EPC).

RESULTS 

Results of Literature Search 

A total of 7,788 potentially relevant citations were identified by searches; 673 articles were 

selected for full-text review; and 28 recently published studies were included, 15 for Key 

Question 1 and 13 for Key Question 2. In addition, 9 studies from the previous VA ESP reviews 

also met inclusion criteria for this review. 

Summary of Results for Key Questions 

Methods to Identify Suicide Risk (Key Question 1) 

Fifteen recently published studies and 4 from the previous VA ESP systematic review evaluated 

the accuracy of methods to identify individuals at risk for suicide and other suicidal self-directed 

violence and met inclusion criteria for this review. These include 2 case-control studies and 17 

case-series studies designed to determine measures of diagnostic accuracy. No studies evaluated 

the adverse effects of risk assessment methods, or compared how accuracy and adverse effects 

vary by settings, delivery modes, targeted populations, or other factors. 

Results of studies indicated estimates of sensitivity ranging from 11% to 100% and area under 

the receiver-operator characteristic curve (AUC) from 0.57 to 0.97. Several risk assessment 

methods had estimates of sensitivity ≥80% or AUC ≥0.70, suggesting fair or better 

discrimination between patients with and without suicides or suicide attempts. Several studies 

used data from electronic medical records or administrative databases to identify individuals with 

known risk factors for suicide. The most relevant study used data from nearly 6 million patients 

of the Veterans Health Administration to create a prediction model to stratify patients according 

to their risk for suicide within the next year. This method had an AUC of 0.761 (95% CI, 0.751 

to 0.771). 

Four additional studies of Veterans were included in the previous VA ESP review. In one study, 

a decision tree for identifying high-risk patients was derived from the Addiction Severity Index 

and variables from VA databases. Sensitivity/specificity varied across the 3 prediction models 

that were evaluated (33%/87%, 72%/63%, 89%/42%). Three studies of Veterans evaluated the 

accuracy of established instruments to predict suicidal attempts and suicide. Results indicated 

high sensitivity/specificity for the Suicide Potential Index (91%/77%), and lower estimates for 

the Beck Depression Inventory (63%/80%) and Affective States Questionnaire (60%/74%). 

The only study of military personnel was based on the Army Study to Assess Risk and 

Resilience in Servicemembers (Army STARRS) and included 40,820 active duty US Army 

soldiers hospitalized with psychiatric admission diagnoses. A risk algorithm to predict suicides 

within one year of hospitalization was developed from administrative data systems and 

demonstrated AUCs as high as 0.89. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Additional studies of non-Veterans evaluated the diagnostic accuracy of the risk instruments, 

including the Affective Intensity Rating Scale, Barwon Health Suicide Risk Assessment, 

Death/suicide Implicit Association Test, SAD PERSONS, Schedule for Nonadaptive and 

Adaptive Personality, Suicide Opinion Questionnaire, Sleep Quality Index, Suicidal Ideation 

Attributes Scale, and Suicide Trigger Scale. Results indicated a wide range of estimates 

depending on the instrument and selected cut-points. 

Figure. Summary of Studies of Methods to Identify Suicide Risk Reporting Area Under the 

Receiver-Operator Characteristic Curve (AUC)

Healthcare Service Interventions for Suicide Prevention (Key Question 2)

Eight studies of the efficacy or effectiveness of population-level healthcare interventions met 

inclusion criteria, including a follow-up analysis of a study that was included in the previous VA 

ESP review. These studies evaluated multi-component initiatives implemented within existing 

organizational structures that included military populations, police officers, college students, and 

healthcare systems. No studies evaluated adverse effects of population-level interventions. 

Suicide rates were lower after interventions in 6 observational studies, including studies of the 

Air Force Suicide Prevention Program, a program for an Army Infantry Division deployed to 

Iraq, and studies of police, college students, and health systems. Suicide rates were not lower in 2 

studies of community programs. Studies were limited by the inherent biases of nonrandomized 

study designs, potential confounders were not considered, and comparison groups may not have 

been comparable. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Five recently published RCTs and 5 trials from a previous VA ESP review of the effectiveness of 

individual-level healthcare interventions met inclusion criteria. No studies specifically evaluated 

adverse effects of individual-level interventions. Trials compared usual care with psychotherapy 

and enrolled outpatient military personnel and non-military psychiatric inpatients or patients at 

acute risk for suicide. 

Only 2 of 10 trials reported statistically significant differences between treatment and usual care. 

In a trial of outpatient active-duty soldiers with recent suicide attempts or ideation, those in a 

brief cognitive behavioral therapy program were less likely to make suicide attempts at 2-year 

follow-up than those in usual care (13.8% versus 40.2%, P=.02; hazard ratio 0.38, 95% CI, 0.16 

to 0.87). In a trial of women with borderline personality disorder, those receiving dialectical 

behavior therapy had fewer suicide attempts than those receiving usual care at one-year followup (23% versus 46%; P=.01). Results of the other trials indicated no statistically significant 

differences between comparisons. However, trials were underpowered to detect differences for 

suicide and suicide attempt outcomes, and were compromised by other methodological 

limitations. 

Research Gaps/Future Research (Key Question 3) 

While a number of research gaps on risk assessment and interventions to prevent suicide and 

other suicidal self-directed violence remain, emerging work and ongoing studies in Veterans and 

military personnel are addressing some of these gaps. 

Most risk assessment methods involve scales or checklists containing self-report items that are 

summed and scored, and specific instruments have rarely been examined in multiple studies.

Even instruments based on large data sources and validated under study conditions require 

further testing in patient populations in order to determine their clinical uses. As a result, none of 

the published studies could be considered definitive for patient care at this point, and the best 

risk assessment method for clinical practice remains uncertain. To address these evidence gaps, 

future research should be directed towards more concerted replication and in-depth examination 

of the most promising instruments. In addition, research on other methods of risk assessment is 

needed, for example, newer approaches that use current information from patients’ electronic 

medical records.

While many studies of risk assessment methods have relied on patient self-report data, a study of 

the computer-administered Implicit Association Test, which uses individuals’ reaction times 

when classifying semantic stimuli in order to predict suicide attempts, is an important exception. 

In addition, individuals with histories of suicide attempts exhibit certain patterns of cognitive 

deficits that can be detected by tasks commonly included in neuropsychological testing batteries.

Future research should test novel approaches to suicide risk assessment that build on this 

developmental work. 

Many studies have examined biological markers for suicide or suicidal behaviors; however, this 

work is currently exploratory. Fewer studies have used neuroimaging to identify associations 

with suicide-related outcomes. While research on biological markers and neuroimaging for 

assessing risk for suicide is expanding, their role in clinical care has yet to be determined. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Studies of population-level healthcare service interventions for suicide prevention included in 

this review examined interventions comprising multiple complex components implemented 

within existing organizational structures. Future studies should be conducted in additional 

populations in order to further validate results of the initial studies, and to demonstrate the 

programs’ applicability to general clinical practice. Additional details about how the program 

components were actually implemented and maintained in practice are also necessary in order to 

establish portable service packages and translate this work to other settings. 

Studies of individual-level interventions generally targeted individuals identified as high-risk for 

suicide based on recent suicide attempts or self-harm or existence of psychiatric conditions. 

However, few studies have evaluated the efficacy or effectiveness of prevention interventions in 

individuals at earlier stages of the suicide pathway. These interventions address known risk 

factors for suicide, such as depression or traumatic brain injury, over the short term, with the 

goal of reducing suicide behaviors over the long term; research is needed to determine the 

validity of this assumption. Studies of interventions targeting protective factors for suicide are 

also needed, such as trials of programs improving social support. 

Individual-level interventions included in this review evaluating the efficacy or effectiveness of 

psychotherapies or care management approaches were typically underpowered to detect 

differences and had high or unclear risk of bias. Improvement of this evidence base will require 

larger, more rigorous RCTs of existing interventions as well as innovative approaches, such as 

novel uses of technology to support or enhance care for individuals at risk for suicide. 

Despite implementation of safety planning in VA care settings, evidence to support its use has 

not yet been established. Peer support specialists in VA settings are currently involved in 

providing general mental health support for Veterans receiving VA care. Continued work in this 

area should focus on establishing training requirements, functions, and eligibility of peer 

supporters, as well as evaluating effectiveness in reducing suicidal behavior. 

DISCUSSION 

Key Findings and Strength of Evidence 

Current conventions do not provide strength of evidence grades for diagnostic accuracy studies. 

Studies of methods of risk assessment that were derived from large databases provided a rigorous 

approach with low risk of bias and high clinical applicability. Results indicated fair or better 

diagnostic accuracy for some of the models (sensitivity ≥80% or AUC ≥0.70). These methods 

should be replicated in additional patient populations to refine the data variables and optimal cutpoints, and further validate findings before they are adapted to clinical care uses. 

Studies based on the diagnostic accuracy of individual instruments and scales are also useful, but 

are currently limited by small sample sizes, methodological limitations, and unclear applicability. 

Risk assessment instruments may provide diagnostic value to specific patient subgroups, such as 

those with previous suicide attempts or co-existing conditions. However, the current evidence 

base includes numerous inconclusive, small studies of a variety of instruments. Instruments 

demonstrating fair to good diagnostic accuracy in these studies should be further tested in larger 

clinical populations. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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The strength of evidence grades for population-level healthcare interventions are insufficient for 

suicide attempt outcomes (no studies), low for suicide outcomes (8 observational studies), and 

insufficient for adverse effects (no studies). Although 6 of the 8 studies of interventions 

suggested reductions in suicide rates, the interventions varied across studies, risk of bias was 

unclear, and the comparability of comparison groups was not established. While the studies 

provided promising initial findings, these interventions should be replicated under more 

controlled conditions, such as RCTs, to strengthen the evidence of their effectiveness. 

The strength of evidence grades for individual-level healthcare interventions are low for suicide 

attempt outcomes (7 trials), insufficient for suicide outcomes (4 trials), and insufficient for 

adverse effects (no studies). The most relevant trial, comparing brief outpatient cognitive 

behavioral therapy versus usual care in Army soldiers, indicated statistically significant 

reductions in suicide attempts with therapy, although risk of bias was unclear. The 4 trials 

reporting suicide outcomes had too few participants and suicide events to determine statistically 

significant differences between treatment and usual care. These interventions require replication 

in larger trials that are sufficiently powered to detect differences between comparisons. 

Applicability 

Of the 37 studies included in this review (including 9 from previous VA ESP reviews), 5 studies 

of risk assessment included Veterans and one included active military personnel; and 3 studies of 

interventions included active military personnel. In addition, inclusion criteria for studies 

enrolling participants outside Veterans and military populations were intended to include 

participants who were similar in age and other demographic characteristics. While these criteria 

may have excluded important studies, they also improved the systematic review’s clinical 

relevance to the VA population. 

Conclusions 

Studies of risk assessment methods to identify individuals at increased risk for suicide and other 

suicidal self-directed violence evaluated numerous different approaches. Methods derived from 

data from electronic medical records, including studies of Veterans and military personnel, were 

robust predictors of subsequent suicide. Studies of various clinician-rated or patient self-report 

risk assessment instruments indicated accuracy that varied across methods and cut-points. 

Studies of multi-component population-level suicide prevention interventions and individual 

cognitive behavioral therapy in active military populations showed reduced suicide attempts and 

suicide. However, evidence is limited by the many single, inconclusive studies of various risk 

assessment instruments and prevention interventions, methodological deficiencies of studies, 

inherent challenges in conducting research in this area, and lack of studies addressing adverse 

effects. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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ABBREVIATIONS TABLE 

Abbreviation Definition

AHRQ Agency for Healthcare Research and Quality

Army STARRS Army Study to Assess Risk and Resilience in Servicemembers

AUC Area under the receiver-operator characteristic (ROC) curve

CAMS Collaborative Assessment and Management of Suicidality

CI Confidence interval

EPC Evidence-based Practice Centers

ESP Evidence-based Synthesis Program

ICD International Classification of Disease Codes

KQ Key Question

NPV Negative predictive value 

NS Not statistically significant

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

PHQ-9 Patient Health Questionnaire

PPV Positive predictive value

PTSD Posttraumatic stress disorder

RCT Randomized controlled trial

ROC Receiver-operator characteristic curve

RR Relative risk

SD Standard deviation

UK United Kingdom

US United States

USPSTF US Preventive Services Task

VA Veterans Affairs
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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EVIDENCE REPORT 

INTRODUCTION 

PURPOSE 

This systematic review updates evidence on the accuracy of methods to identify individuals at 

increased risk for suicide, and the efficacy/effectiveness and adverse effects of healthcare service 

interventions in reducing suicide and other suicidal self-directed violence. Important areas of 

ongoing research and current evidence gaps on suicide prevention are also addressed. This report 

includes studies relevant to healthcare services provided to Veterans and military personnel in 

the United States (US). 

Previous systematic reviews by the US Department of Veterans Affairs (VA) Evidence-based 

Synthesis Program (ESP) focused on strategies for suicide prevention in Veterans,1 suicide risk 

factors and risk assessment tools,2

 and suicide prevention interventions and referral/follow-up 

services.3

 While many of the studies included in the previous reviews fall outside the scope of 

this update, relevant studies are included in order to consolidate the evidence. 

BACKGROUND

Suicide is a major health concern in the US. A recent estimate of the overall US crude suicide 

rate was 12.4 per 100,000 population; the rate for males was nearly four times that for females 

(19.8 and 5.3 per 100,000).4

 Suicide rates also vary by age and other demographic 

characteristics.4 Several factors have been associated with increased risk for suicide in 

epidemiological studies. The most consistently associated risk factors include the presence of 

mental health disorders, particularly depression, posttraumatic stress disorder, and substance 

abuse.2

Veterans and military personnel represent 20% of all known suicides in the US.5 Rates of suicide 

increased during the wars in Afghanistan and Iraq,

6 and Veterans of these wars who reported 

suicidal ideation identify challenges during and after deployment as major contributors to their 

distress.7

 Between 2000 and 2010, the suicide rate among Veterans rose higher than the rate 

among civilians.8 Female Veterans are at especially high risk relative to other women.

8 These 

trends have led to new initiatives within the VA and military to address suicide prevention. 

One such initiative is the Army Study to Assess Risk and Resilience in Servicemembers (Army 

STARRS), a multi-component epidemiological and neurobiological study. Army STARRS is

designed to increase knowledge about risk and resilience factors for suicidality and support 

evidence-based recommendations to reduce suicides specifically among Army soldiers.9

Determination of risk and resilience factors in this population could lead to the development of 

additional methods to identify individuals at increased risk for suicide who may benefit from 

prevention interventions.10,11

CURRENT PRACTICES

During the year prior to suicide, an estimated 77% of individuals make contact with primary care 

and 32% with mental health care clinicians.

12 These encounters provide opportunities for suicide 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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risk assessment and treatment of physical and psychiatric conditions that are associated with 

suicide.13 However, screening for suicide risk in general medical practice is not part of standard 

care in the US. The US Preventive Services Task (USPSTF) recently concluded that there is 

currently not enough research to support routine screening for suicide risk14 based on a 

systematic review of studies of screening and prevention interventions.15,16 This recommendation 

was intended for patients in primary care settings that do not have existing mental health 

disorders, emotional distress, or previous suicide attempts, and it did not specifically address 

Veterans and military personnel. The USPSTF encouraged primary care clinicians to be alert to 

the possibility of suicide during periods of high suicide risk, such as after discharge from a 

psychiatric facility or following an episode of self-harm or suicide attempt.14 Other 

recommendations from the USPSTF support routine screening in primary care for conditions 

associated with increased suicide risk. These include screening for depression,

17 alcohol use,18

and intimate partner violence.19 

The Veterans Health Administration and the Department of Defense issued their Clinical 

Practice Guideline for the Assessment and Management of Suicide Risk in 2013.20 Goals of the 

guideline are to reduce practice variation and provide a structural framework to reduce suicide 

and other suicidal self-directed violence, provide evidence-based recommendations for 

healthcare providers, and support the development of practice-based evidence. This guideline is 

organized around 3 clinical algorithms, including Assessment and Management of Risk for 

Suicide in Primary Care; Evaluation and Management of Risk for Suicide by Behavioral Health 

Providers; and Management of Patients at High Acute Risk for Suicide. However, the guideline 

does not recommend a specific risk assessment method or prevention intervention because of the 

lack of adequate supporting evidence. 

Efforts to prevent suicide in individuals at high risk generally include treatment of underlying 

conditions and psychotherapy.1,3

 Psychotherapy most often includes cognitive behavioral therapy 

and related approaches, such as dialectical behavior therapy and problem-solving therapy. 

Additional efforts include restriction of access to lethal means, including firearms and toxic 

agents.1

In addition to individual-level approaches to suicide prevention, initiatives have been 

implemented at organizational, health system, and community levels. These include multifaceted 

interventions emphasizing education and awareness, suicide hotlines and outreach programs, 

treatment coordination programs, and others. However, despite the existence of many types of 

services, very few studies demonstrating their effectiveness have been published.1 As a result, 

their influence on suicide prevention remains unclear.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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METHODS 

TOPIC DEVELOPMENT 

This project was nominated by Theresa Gleason, PhD, (Acting) Deputy Chief Research and 

Development Officer at the VA, with input from a technical expert panel. It is intended to update 

3 previous VA ESP systematic reviews related to suicide screening and prevention published in 

2009 and 2012.1-3 The scope and key questions of this report were determined during a topic 

refinement process that included a preliminary review of published peer-reviewed literature, 

discussion with internal partners and investigators, and consultation with content experts and key 

stakeholders. 

This systematic review focuses on the accuracy of suicide risk assessment methods and the 

efficacy/effectiveness of suicide prevention interventions. Studies of associations between risk 

and protective factors and suicide are not included because of an ongoing large epidemiological 

study specifically among Army soldiers, Army STARRS, which will likely provide the strongest 

and most applicable evidence on this topic.9

 A protocol describing the review was posted to the 

PROSPERO International Prospective Register of Systematic Reviews website before the review

was initiated (http://www.crd.york.ac.uk/PROSPERO; registration number CRD42015019089).

21

This review follows established systematic review methodology.22

Investigators created an analytic framework outlining the key questions, patient populations, 

interventions, and outcomes (Figure 1). 

Figure 1. Analytic Framework
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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This systematic review is an update of previous VA ESP reviews that addresses the following 

key questions: 

Key Question 1 

A) What are the accuracy and adverse effects of methods to identify Veterans and military 

personnel at increased risk for suicide and other suicidal self-directed violence? 

B) Does accuracy and adverse effects vary by settings, delivery modes, targeted populations, or 

other factors?

Key Question 2 

What are the efficacy/effectiveness and adverse effects of suicide prevention interventions in 

reducing rates of suicide and other suicidal self-directed violence in Veterans and military 

personnel? Interventions include healthcare services directed towards: 

A) Populations (eg, hotlines, outreach programs). 

B) Individuals (eg, case management, follow-up). 

Key Question 3 

What are important areas of ongoing research and current evidence gaps in research on suicide 

prevention in Veterans and military personnel, and how could they be addressed by future 

research?

Outcomes related to the efficacy and effectiveness of suicide risk assessment and prevention 

interventions included in this review are reduced suicide and other suicidal self-directed 

violence. Suicidal self-directed violence is behavior against oneself that deliberately results in 

injury or the potential for injury with evidence of suicidal intent, as defined by the Centers for 

Disease Control23 and the VA.

24 Suicide is a fatal outcome of suicidal self-directed violence. 

Other types of self-directed violence are outside the scope of this review, including non-suicidal 

self-directed violence and self-harm, or composite outcomes that include these behaviors. 

Adverse effects of suicide risk assessment and prevention interventions include any outcomes 

related to these activities that are not beneficial to the patients experiencing them. Criteria for 

adverse effects are intentionally broad, but need to be clinically relevant. Adverse effects 

generally include health outcomes as well as other types of outcomes, including anxiety and 

distress, labeling, and stigma.

SEARCH STRATEGY

In conjunction with the systematic review investigators, a research librarian searched electronic 

bibliographic databases for relevant research published between January 1, 2008 and September 

11, 2015, including MEDLINE, PubMed, PsycINFO, SocINDEX, Cochrane Central Register of 

Controlled Trials, and the Cochrane Database of Systematic Reviews. These dates were selected 

in order to capture studies published since the search dates of the previous VA ESP systematic 

reviews on this topic.1-3 Search terms and strategies are described in Appendix A. A search of 

the grey literature was conducted on July 16, 2015. In addition, citations from reference lists of 

relevant primary studies, reviews, conferences proceedings, and from clinical and research 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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experts were reviewed. All citations were imported into an electronic database (EndNote® X6, 

Thomson Reuters). 

STUDY SELECTION

Titles and abstracts were reviewed for inclusion using pre-specified eligibility criteria 

(Appendix B). Full-text articles identified as potentially relevant to the key questions were 

retrieved for further review and were independently examined by 2 reviewers using the 

eligibility criteria. Disagreements were resolved through consensus using a third reviewer. 

Consistent with the previous VA ESP reviews, eligible studies included populations of Veterans, 

military personnel, and demographically comparable non-Veteran/military adults aged 18 and 

older from the US, United Kingdom (UK), Canada, New Zealand, and Australia. These countries 

were chosen because of their similarities to the US in terms of healthcare services as well as their 

involvement in the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts. 

Studies enrolling participants substantially different from the general VA/military population

(eg, children and adolescents) or with serious co-morbidities (eg, advanced cancer) were outside 

the scope of this review. Also, only English-language articles were included. Systematic reviews 

were eligible if they were timely, and contained relevant studies that addressed the key questions 

and met inclusion criteria for this update. 

For Key Question 1, included studies evaluated the diagnostic accuracy and adverse effects of 

methods to assess risk for suicide and other suicidal self-directed violence, including 

instruments, checklists, and other approaches appropriate for clinical settings. Outcomes 

included measures of the accuracy of the risk assessment method (Table 1). Sensitivity measures 

were emphasized in this review because the serious morbidity and potential mortality associated 

with suicidal self-directed violence makes identifying individuals at risk for suicide, and thus 

providing opportunities for prevention interventions, more important than identifying individuals 

who at not at risk. This approach prioritizes sensitivity over specificity. Studies considering the 

setting, mode of delivery, and timing of risk assessment were also included. Studies were 

excluded that primarily determined associations between individual risk factors and suicidal selfdirected violence, evaluated psychometric characteristics of instruments, or provided only 

descriptions of methods without reporting measures of accuracy. 

Table 1. Measures of Test Accuracy

Statistical Term Description

Sensitivity Probability of a positive test among patients with the condition.

Specificity Probability of a negative test among patients without the condition.

Positive predictive value (PPV) Probability of the condition among patients with a positive test.

Negative predictive value (NPV) Probability of not having the condition among patients with a negative test.

Receiver-operator characteristic 

curve (ROC)

A graph of sensitivity/(1-specificity).

Area under the ROC curve (AUC) Reflection of how good the test is at discriminating between patients with and 

without the condition. Also referred to as the c-statistic. The greater the area, 

the better the test (0.50 no better than chance; 0.51-0.69 poor; 0.70-0.79 fair;

0.80-0.89 good; 0.90-0.99 excellent; 1.0 perfect).
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For Key Question 2, studies of the efficacy or effectiveness of interventions were included that 

were specifically designed to prevent suicide and other suicidal self-directed violence. Eligible 

study designs included randomized controlled trials (RCTs), observational studies with 

comparison groups, and systematic reviews with these study designs. Efficacy studies evaluate 

an intervention under controlled circumstances, while effectiveness studies generally reflect 

more real-world conditions. Interventions included healthcare services directed towards 

populations (eg, hotlines, outreach programs) or individuals (eg, case management, follow-up 

services) that are clinically relevant to medical practice in the US. Both primary and secondary 

prevention studies were included. Primary prevention interventions are intended for individuals 

who have not experienced previous suicidal self-directed violence, while secondary prevention 

interventions are for those who have had previous episodes. Studies of interventions that are 

intended to primarily treat co-existing conditions and studies of pharmacotherapy were outside 

the scope of this update. 

Key Question 3 addresses evidence gaps identified from the synthesis of studies addressing Key 

Questions 1 and 2. Consequently, studies included for Key Question 3 were identified from the 

searches for Key Questions 1 and 2. In addition, ongoing studies were selected from websites 

and other sources identified by our search of grey literature based on their relevance to the key 

questions. Our list of ongoing studies is likely incomplete because not all ongoing studies are 

included in these accessible sources.

DATA ABSTRACTION 

Data from included studies for Key Questions 1 and 2 were abstracted into a customized, prepiloted database by one reviewer and over-read for accuracy by a second reviewer. Abstracted 

information included study design, setting, population, methodology, and results. Additional 

information for Key Question 1 included measures of accuracy, including sensitivity, specificity, 

positive and negative predictive value, or similar outcomes. Additional information for Key 

Question 2 included details of the intervention and control groups, important co-interventions, 

implementation factors, suicidal self-directed violence outcomes (suicide attempt and suicide), 

and other relevant outcomes. 

QUALITY ASSESSMENT 

Two reviewers independently assessed the risk of bias of included studies using pre-specified 

criteria for RCTs,

25 observational studies,26,27 and diagnostic accuracy studies26,28 (Appendix C). 

Each study was given an overall summary assessment of low, high, or unclear risk of bias. 

Disagreements were resolved through consensus using a third reviewer. 

DATA SYNTHESIS 

Since this review is an update of previous VA ESP reviews, conclusions are based on qualitative 

synthesis of the findings of recently published studies as well as relevant studies from the 

previous reviews. Measures, interventions, outcomes, and study participants were too 

heterogeneous to combine in statistical meta-analysis. 
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RATING THE BODY OF EVIDENCE

The overall strength of evidence for studies of interventions reviewed for Key Question 2 was 

determined using a method developed for the Agency for Healthcare Research and Quality’s 

(AHRQ) Evidence-based Practice Centers (EPC).29 This method does not provide strength of 

evidence grades for the diagnostic accuracy studies reviewed for Key Question 1. The AHRQ 

EPC method considers study limitations, directness, consistency, precision, and reporting bias to 

classify the strength of evidence for individual outcomes independently for RCTs and 

observational studies. Supplemental domains include dose-response association, plausible 

confounding that would decrease the observed effect, and strength of association, as well as 

separate guidance for applicability. Ratings were based on the following criteria:

High = Very confident that the estimate of effect lies close to the true effect for this 

outcome. The body of evidence has few or no deficiencies, the findings are stable, and 

another study would not change the conclusions.

Moderate = Moderately confident that the estimate of effect lies close to the true effect 

for this outcome. The body of evidence has some deficiencies and the findings are likely 

to be stable, but some doubt remains. 

Low = Limited confidence that the estimate of effect lies close to the true effect for this 

outcome. The body of evidence has major or numerous deficiencies (or both).

Additional evidence is needed before concluding either that the findings are stable or 

that the estimate of effect is close to the true effect.

Insufficient = No evidence, unable to estimate an effect, or no confidence in the estimate 

of effect for this outcome. No evidence is available or the body of evidence has 

unacceptable deficiencies, precluding reaching a conclusion.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Search results: 

7788 references*

Pulled for full-text review: 

673 references

Included studies: 28 (from 

29 publications)

Excluded = 7115 references

Excluded = 644 references†

Study did not involve diagnostic accuracy of suicide 

risk assessment (KQ 1) or a healthcare intervention 

to prevent suicide (KQ 2): 226

Ineligible publication type: 129

Ineligible outcome: 119

Ineligible country: 110

Ineligible population or setting: 24

Ineligible systematic review due to scope, inclusion 

criteria, or limitations in quality: 18

Ineligible study design or no comparison group: 18

KQ 1 (risk 

assessment):

15 studies

*7708 references were identified through database searches (Appendix A), and an additional 80 references were 

identified from the bibliographies of relevant systematic reviews and primary studies.

†Appendix B describes the inclusion/exclusion criteria; studies excluded at the full-text level are listed in 

Appendix E. 

KQ 2 

(interventions):

13 studies (from 14 

publications)

RESULTS 

SEARCH RESULTS 

Results of the literature search and selection process are summarized in the literature flow 

diagram (Figure 2). Database searches resulted in 7,708 potentially relevant citations and 

another 80 were identified from the bibliographies of studies and systematic reviews, for a total 

of 7,788 citations. After review of abstracts and titles, 673 articles were selected for full-text 

review. After dual review of full-text articles, 28 recently published studies were included, 15 for 

Key Question 1 and 13 for Key Question 2. In addition, 9 studies from the previous VA ESP 

reviews also met inclusion criteria for this review.

Figure 2. Literature Flow Chart
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KEY QUESTION 1:

A) What are the accuracy and adverse effects of methods to identify 

Veterans and military personnel at increased risk for suicide and 

other suicidal self-directed violence?

B) Does accuracy and adverse effects vary by settings, delivery 

modes, targeted populations, or other factors? 

Summary of Findings

Studies Included in Previous Systematic Reviews

Five previously published systematic reviews included studies of methods to identify individuals 

at risk for suicide and other suicidal self-directed violence (Table 2).2,16,30-32 The systematic 

reviews are provided in this report for context. Only 4 studies included in the previous VA ESP 

report2 are relevant to the key questions in this review (Table 3).33-36 All 4 studies enrolled 

Veterans, specifically those with suicidal ideation,36 primary affective disorders,35 traumatic 

brain injury,33 and posttraumatic stress disorder.34 One study derived a decision tree for 

identifying patients at high risk for suicide attempts,36 while 3 studies evaluated the accuracy of 

instruments to predict suicide and suicide attempts (instruments described in Table 4).

33-35

Studies had important methodological limitations resulting in high33,34 or unclear35,36 risk of bias 

ratings, including biased or unclear selection criteria for the study populations, non-standardized

risk assessment procedures, and inadequate outcome assessments (Table 5).

In one study, data from 5,671 Veterans with suicidal ideation, identified from a larger cohort of

substance abuse patients at 150 VA Medical Centers nationwide, were used to derive a decision 

tree to identify patients who reported suicide attempts within the 30 days prior to assessment.36

Results were expressed at various cut-points representing the percentages of patients with suicide

attempts in the past 30 days. At a 20% cut-point, the decision tree had 72% sensitivity and 63% 

specificity; at a 10% cut-point, it had 89% sensitivity and 42% specificity. 

A study of 283 Veterans with primary affective disorders examined the use of a brief screening 

tool, the Affective States Questionnaire, as a predictor of suicidal behavior within 3 months of

assessment.35 Results indicated 60% sensitivity and 74% specificity. A study of 154 Veterans 

with traumatic brain injury evaluated the Personality Assessment Inventory and examined the 

use of 2 subscales, the Suicide Potential Index and the Suicide Ideation scale, to predict suicidal 

self-directed violence within the next 2 years.33 In this study, only the Suicide Potential Index 

subscale was predictive, and when combined with the known risk factor of history of suicidal 

behavior, it demonstrated 90.9% sensitivity and 95.1% specificity. A study of the Beck 

Depression Inventory included 630 male Veterans entering a residential treatment program for 

posttraumatic stress disorder.34 Results indicated that the Beck Depression Inventory score along 

with history of suicide attempt in the 4 months prior to intake predicted suicide within 4 months 

after discharge with 63% sensitivity and 80% specificity in the exploratory sample. However, 

sensitivity was only 11% when tested in a replication sample.
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Table 2. Previous Systematic Reviews of Methods to Identify Individuals at Risk for Suicide and Other Suicidal Self-Directed 

Violence

Author, 

Year

Search 

Dates

Included 

Populations Suicide Risk Methods

Suicide-Related 

Outcomes Results Relevant to the Current Review

Batterham,

201430

To March, 

2014

General adult 

population.

Self-report measures that could be 

used in population-based research 

of adults. Excluded measures 

requiring interviewer or clinician 

administration.

Suicidal thoughts and 

behaviors. 

19 eligible self-report measures were identified; 

however, diagnostic accuracy was not reported. 

O’Connor,

201315,16

2002-July, 

2012

Adolescents, adults, 

older adults.

Instruments used in primary care 

or similar populations to identify 

individuals at risk for suicide. 

Increased suicide risk 

(usually suicidal 

ideation) relative to a 

reference standard.

5 relevant studies of adults were included; no 

studies considered suicide attempts immediately 

after screening as a reference standard. One trial 

of potential adverse effects of screening in adults 

indicated no increased suicidal ideation or 

suicide attempts at 2-week follow-up.37

Haney,

20122* 

2005-

November, 

2011

Veteran and 

military 

populations.

Assessment tools for the risk of 

engaging in suicidal self-directed 

violence.

Suicidal self-directed 

violence, including 

suicide attempt and 

suicide.

5 relevant studies were included, 4 reported 

diagnostic accuracy (summarized in Table 3).

Mann,

200531

1966-June, 

2005

Not specified. Screening tools for at-risk 

individuals.

Suicide and suicide 

attempt.

3 studies were identified; however diagnostic

accuracy was not reported.

Gaynes,

200432

1966-

October, 

2002

Primary care 

patients with 

previously 

unidentified suicide 

risk.

Screening tools to detect suicide 

risk.

Comparison with a 

gold standard.

No studies were identified that meet eligibility 

criteria for the current review.

*Previous VA ESP review on suicide risk in Veterans and military personnel.
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Recently Published Studies

Fifteen new studies evaluated the accuracy of methods to identify individuals at risk for suicide 

and other suicidal self-directed violence met inclusion criteria (Table 3).38-52 No studies 

evaluated the adverse effects of risk assessment methods, or compared how effectiveness and 

adverse effects vary by settings, delivery modes, targeted populations, or other factors. 

One study was conducted in the Veterans Health Administration and included only Veterans,43

and one study specifically enrolled military personnel.42 Ten studies were based in the US, 3 in 

Australia, one in England, and one in Canada, and they included from 157 to over 5.9 million 

participants. Studies enrolled participants from the community, online, emergency departments, 

and psychiatry services, or used data from existing patient medical records or administrative 

data. Most studies included high-risk populations, including adults presenting to emergency 

departments with suicide attempts,

39,44,46,49-51 or who had psychiatric hospitalizations or 

psychiatric risk factors that put them at higher risk for suicide,40-42,45,47,52 most commonly 

depression or previous suicide attempts. Two studies were designed as nested case-control 

studies,38,43 while the majority were case series studies. 

Ten studies used one or more clinician-rated or patient self-report instruments to assess 

individual levels of risk (Table 4).38-41,44,48-52 These included the Affective Intensity Rating 

Scale, Barwon Health Suicide Risk Assessment, Death/suicide Implicit Association Test, SelfInjurious Thoughts and Behaviors Interview, SAD PERSONS, Schedule for Nonadaptive and 

Adaptive Personality, Sleep Quality Index, Suicidal Ideation Attributes Scale, Suicide Opinion 

Questionnaire, and Suicide Trigger Scale. Instruments incorporated questions and scales 

indicating the presence and severity of known or suspected suicide risk factors. The studies 

determined how well participants’ responses predicted suicidal behaviors. In one study, 

participants’ responses to 9 separate scales were analyzed in various combinations to determine a 

model with the best diagnostic accuracy.40 

Five studies used existing data from electronic medical records or administrative databases to 

identify suicide risk factors in populations of patients, and then stratified the patient populations 

by levels of suicide risk using regression analysis.42,43,45-47 One study compared the performance 

of this type of population-level screening approach with a clinician-rated screening tool.47

Outcome measures included suicide attempts,39-41,44,48-51 suicide,38,42,43,46 or both outcomes45,47,52

occurring within a specific time period that varied from the recent past to 10 years after risk 

assessment. Methods to determine suicide attempt outcomes included the Columbia 

Classification Algorithm of Suicide Assessment, Columbia Suicide Severity Rating Scale, SelfInjurious Thoughts and Behaviors Interview, Longitudinal Interval Follow-up Evaluation semistructured interview, International Classification of Disease Codes (ICD) from patient medical 

records, and an in-depth assessment of suicidal behavior. Suicide was confirmed using death 

certificates, the National Death Index, and ICD codes (ICD-9 and ICD-10) from patient medical 

records. 

Studies generally used regression analysis to determine relationships between predictors and 

outcomes and to derive predictive models. Estimates of the area under the receiver-operator 

characteristic curve (ROC AUC) were used to indicate the accuracy of the methods and 

determine optimum cut-points to estimate sensitivity, specificity, positive predictive value 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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(PPV), and negative predictive value (NPV). Three studies derived models from development 

data sets and tested them in validation data sets.43,46,47

Four studies had important methodological limitations resulting in high risk of bias ratings;41,49-51

risk of bias was unclear in 8 studies;38-40,44,45,47,48,52 and low in 3 studies42,43,46 (Table 5). Major 

limitations included small sample sizes, including 5 with sample sizes less than 200;41,44,49-51 high 

or unclear loss to follow-up;39-41,43,44,50,51 and potentially biased participant selection.38,40,41,44,49-52 

Results of studies indicated estimates of sensitivity ranging from 11% to 100% and AUC from 

0.57 to 0.97 (Figures 3 and 4). Several risk assessment methods had estimates of sensitivity 

≥80% or AUC ≥0.70, suggesting fair or better discrimination between patients with and without 

suicide or suicide attempts. These methods include SAD PERSONS and variations,39 Suicide 

Opinion Questionnaire,41 ReACT Self Harm Rule,46 Suicidal Ideation Attributes Scale,

48

modification of the Affective Intensity Rating Scale,

49 Suicide Trigger Scale,50,51 Schedule for 

Nonadaptive and Adaptive Personality Self-harm Subscale,

52 and derived models.40,42,43,47

Methods from studies from the previous VA ESP review with similar results include the Suicide 

Potential Index subscale of the Personality Assessment Inventory33 and a decision tree with 

predictors of suicide attempts.

36
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Figure 3. Summary of Studies of Methods to Identify Suicide Risk Reporting Sensitivity and Specificity
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Figure 4. Summary of Studies of Methods to Identify Suicide Risk Reporting Area Under the Receiver-Operator Characteristic 

Curve (AUC) 
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Descriptions of Individual Studies

The only new study of Veterans used electronic medical records from nearly 6 million patients of 

the Veterans Health Administration to create a population-level prediction model to stratify 

patients according to their risk for suicide.43 The model explored 381 predictor variables 

including demographic characteristics; period of military service; military service-related 

disability, homelessness, or other trauma; mental health diagnoses and assessments; Veterans 

Health Administration service utilization; and medication use. The AUC estimate for the model 

was 0.761 (95% confidence interval [CI], 0.751 to 0.771). Results of the study suggested that the 

model was a better predictor for suicide than the current clinical practice standard of healthcare 

providers “flagging” medical records of individuals believed to be at higher risk of suicide. The 

study had low risk of bias; limitations included unclear handling of missing data and reporting of 

accuracy measures. 

The only study of military personnel was based on Army STARRS and included 40,820 active 

duty US Army soldiers hospitalized with psychiatric admission diagnoses.42 The study used 

machine learning methods that included up to 421 individual predictor variables extracted from 

38 US Army and Department of Defense administrative data systems to develop a risk algorithm 

to predict suicides within one year of hospitalization. The predictor variables represented several 

known risk factors, such as sociodemographics, history of suicidal behaviors, medical and 

psychiatric history, quality of care, time since hospital discharge, and psychopathological risk 

factors, as well as US Army career variables, criminal perpetration and victimization, and access 

to weapons. Results showed that a model with 73 of the predictor variables was most accurate in 

predicting suicides (AUC 0.89), although a model with only 20 predictors was almost as accurate 

(AUC 0.84). The study had low risk of bias; limitations included lack of reporting of 

demographic characteristics and source of suicide outcome data, and not providing lists of 

predictors used in the various models.

Another model used a similar method, but eliminated variables that did not significantly improve 

its predictive performance.46 With this approach, the model was condensed to 4 items, termed the 

ReACT Self-Harm Rule, and included self-harm in the past year, living alone or homelessness, 

cutting as a method of harm, and treatment for a current psychiatric disorder. Presentation with 

self-harm was classified as either low risk or high to moderate risk based on the presence of one

or more risk factors. Data from 18,680 patients presenting to emergency departments with selfharm in England (totaling 29,571 self-harm episodes) indicated sensitivity of 88% and specificity 

of 24% for predicting suicide within 6 months. The study had low risk of bias; limitations

included differing methods of data collection across the study sites and unclear loss to follow-up.

Two studies used electronic medical records from a large regional healthcare provider (Barwon 

Health) in Australia to determine the diagnostic accuracy of their standard risk assessment tool, 

the clinician-rated Barwon Health Suicide Risk Assessment checklist.45,47 The first study used 

27,061 risk assessments from 8,739 patients receiving care at Mental Health, Drugs and Alcohol 

Services to evaluate the ability of 15 machine learning algorithms to discriminate between 

patients who died by suicide, had attempted suicide, and who do not exhibit suicidal self-directed 

violence within the 6-year study period.45 The study found that the algorithms typically had 

sensitivities of 35% to 50% depending on the model, and average specificities of 65% to 70%. In 

the second study, the electronic medical records from 7,399 patients were used to derive a risk 

stratification model.47 The model’s diagnostic accuracy was then compared to the Barwon Health 
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Suicide Risk Assessment. The model had a sensitivity of 70% and specificity of 72% in 

predicting suicide attempt or suicide at 3 months. Results indicated that that the model was more 

accurate at various time points between 1 and 6 months after assessment than the clinician-rated 

checklist (AUC at 3 months: model 0.79 [95% CI, 0.72 to 0.84] versus checklist 0.58 [95% CI, 

0.50 to 0.66]). Both studies had unclear risk of bias; limitations included incomplete reporting of 

the scoring method for the clinician-rated tool, unclear loss to follow-up, low rate of events (3 

suicides in the validation cohort within 3 months),47 and use of a composite outcome measure

that potentially included some events of self-harm without intent to die. 

A study of 304 adults with major depressive disorder or bipolar disorder compared the accuracy 

of several prognostic models to predict suicide attempts within 2 years of assessment.

40 The 

models included combinations of 15 variables including demographic information, results of 

psychiatric instruments, and their interactions. Using a cut-point score of 0.25, which weighs 

false-negative results 3 times more highly than false-positive results in order to prioritize 

sensitivity over specificity, a 3-term model (past suicide attempt, smoking status, and suicidal 

ideation score) demonstrated sensitivity of 75% and specificity of 75%. More complex models 

had similar results (9-term model, 71% sensitivity and 77% specificity; 40-term model, 71%

sensitivity and 80% specificity). The study had unclear risk of bias; limitations included potential 

selection bias, small sample size, and unclear loss to follow-up and outcome measurement. 

The diagnostic accuracies of the SAD PERSONS scale, a clinician-rated suicide risk assessment 

checklist consisting of 10 risk factors, and a modified version that weighs some factors more 

heavily, were evaluated in a Canadian study.39 The study included 4,019 consecutive adults who 

were referred to psychiatric services at the emergency departments of 2 large hospitals. A revised 

5-item version that included only items independently predictive of suicide attempts within 6 

months had a sensitivity of 93.5% and specificity of 27.9%. A revised 9-item version identified 

patients with current presentations of suicide attempt with a sensitivity of 90.4% and specificity 

of 65.6%. The revised versions demonstrated higher diagnostic accuracy than the complete and 

modified SAD PERSONS scales. The study had low risk of bias; limitations included an 

undefined patient population and unknown loss to follow-up (assessment of suicide attempts was 

restricted to patients who returned to the same hospitals).

A study of 733 adults with either a personality disorder or major depressive disorder determined 

the accuracy of the Self-Harm Subscale of a comprehensive personality inventory, the Schedule 

for Nonadaptive and Adaptive Personality.52 Results found that at a cut-point of 10, the subscale 

predicted suicide or suicide attempt at one year with 84% sensitivity and 70% specificity (AUC 

0.855); a cut-point of 11 had 78% sensitivity and 77% specificity. The study had unclear risk of 

bias; study limitations included potentially biased patient selection methods, unclear blinding of 

outcome assessors, and partial reliance on participants’ family members to report suicide deaths. 

Diagnostic accuracy of a brief computer-administered Implicit Association Test was evaluated 

among 91 adults with histories of suicide attempt presenting to a psychiatric emergency 

department.44 Unlike patient self-report instruments, this test uses individuals’ reaction times 

when classifying semantic stimuli in order to predict suicide attempts. Scores representing 

associations between self and death/suicide, as opposed to self and life, predicted suicide 

attempts at 6 months with 50% sensitivity and 81% specificity. The study had unclear risk of 

bias; limitations included small sample size and unclear loss to follow-up.
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Three studies evaluated how well scales that measure a specific suicide risk factor predict 

suicidal behavior.38,41,48 The Suicidal Ideation Attributes Scale, a short online self-report survey 

of the frequency and severity of suicidal thoughts, was administered among 1,352 participants 

from the general population in Australia.48 Results indicated that use of a low cut-point score 

identified individuals who had made suicide preparations or attempts over the past year with 

85% sensitivity and 63.3% specificity. A higher cut-point score improved specificity (94.9%) but 

lowered sensitivity (50%). The study had unclear risk of bias; study limitations included the 

small number of suicide attempts and unknown accuracy of online reporting of risk factors and 

outcomes.

A case-control study of 420 adults over the age of 65 evaluated the Sleep Quality Index, a brief 

self-report measure of sleep quality.38 Results indicated AUC of 0.685 (95% CI, 0.549 to 0.820) 

for predicting suicide over a 10-year observation period. The study had unclear risk of bias; 

limitations included undefined inclusion criteria, small sample size, and unclear blinding. A 

study of 91 adult psychiatric inpatients evaluated the accuracy of a 100-item self-report survey 

on attitudes toward suicide, the Suicide Opinion Questionnaire, in predicting suicide attempts 

within 2 months of discharge.41 A model using only 20 of the items had a sensitivity of 85.7% 

and specificity of 97% (AUC 0.944), while a condensed 9-item model had 85.7% sensitivity and 

69.7% specificity (AUC 0.861). The study had high risk of bias; study limitations included 

potentially biased patient selection, small sample size, high loss to follow-up, and inconsistent 

timing of risk factor assessment.

The Suicide Trigger Scale was evaluated in 2 small studies of adults presenting to emergency 

departments with suicidal ideation or suicide attempts.50,51 This self-report instrument measures 

the presence of a distinct panic-like symptom, the suicide trigger state, suggesting the risk of 

imminent suicide. This state is characterized by frantic hopelessness, overwhelming profusion of 

negative thoughts, and near psychotic somatization, such as feeling as if excessive thoughts are 

going to make ones’ head explode. A study assessing the scale’s ability to predict suicide 

attempts within 6 months of hospital discharge found that a 6-item subscale had a sensitivity of 

92.3% and specificity of 63.4% at the cut-point score of 2, and 69.2% sensitivity and 78.0% 

specificity at the cut-point score of 3.51 This subscale had greater accuracy than the complete 42-

item scale (69.2% sensitivity, 68.3% specificity). The second study attempted to determine 

outcomes within one year, but 90% of participants were lost to follow-up.50 Both studies had 

high risk of bias; limitations included small sample sizes (N = 183 and N = 161), potentially 

biased patient selection, and high loss to follow-up. 

The Affective Intensity Rating scale, measuring the presence and intensity of positive and 

negative affects experienced in the previous 72 hours, was tested in a small sample of patients 

presenting to an emergency department with suicidal ideation or suicide attempts.49 A subscale 

consisting of self-report items that were statistically significant predictors was able to distinguish 

patients with suicide attempts from those with ideation alone (86.7% sensitivity, 41.7% 

specificity). The study had high risk of bias; limitations included small sample size (N = 176), 

potentially biased patient selection, and differences among participants regarding the timing of 

the assessment.
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Table 3. Studies of the Accuracy of Methods to Identify Individuals at Risk for Suicide and Other Suicidal Self-directed Violence

Author, 

Year Study Design; Approach N; Population

Risk Assessment 

Method Outcome Measures of Accuracy

Recently Published Studies

Bernert,

201438

Nested case-control study; used 

hierarchical logistic multiple 

regression analysis controlled 

for baseline depression; 

determined AUC estimates.

420 older adults 

selected from a larger 

US cohort of 14,456 

community-dwelling 

older adults; 20 suicide 

decedents and 400 

controls matched on 

age, sex, and study site.

Sleep Quality Index, a 

5-item self-report 

measure.

Suicide within 10-

year observation 

period as listed on 

official death 

certificates (ICD9 code between 

950 and 959).

AUC 0.685 (95% CI, 0.549 to 0.820).

Sleep Quality Index total scores distinguished suicide 

decedents from matched controls (P=.005).

Bolton,

201239

Case series; logistic regression 

analysis; used AUC estimates to 

determine optimum cut-points 

to estimate sensitivity, 

specificity, PPV, NPV.

4,019 adults referred to 

psychiatric services at 

emergency 

departments of 2 large 

hospitals in Canada.

SAD PERSONS and 

Modified SAD 

PERSONS, 10-item 

checklists.

Current suicide 

attempts and 

suicide attempts 

within 6 months 

as defined by the 

Columbia 

Classification 

Algorithm of 

Suicide 

Assessment.

SAD PERSONS:

-Current suicide attempt, score >3: 73.3% sensitivity, 

43.8% specificity; PPV 33.0%, NPV 83.0%.

AUC 0.657 (95% CI, 0.63 to 0.69), P<0.001.

-Future suicide attempt, score >2: 88.8% sensitivity, 

19.6% specificity; PPV 3.1%, NPV 98.4%.

AUC 0.572 (95% CI, 0.51 to 0.64).

Modified SAD PERSONS: 

-Current suicide attempt, score of >3: 81.3% 

sensitivity, 36.4% specificity; PPV 31.8%, NPV 84.2%.

AUC 0.738 (95% CI, 0.71 to 0.77), P<0.001.

-Future suicide attempt, cut score of >3: 81.6% 

sensitivity, 28.3% specificity; PPV 3.2%, NPV 98.2%. 

AUC 0.613 (95% CI, 0.55 to 0.68), P<0.01.

9-item risk model (sex, age 19-45, depression or 

hopelessness, previous attempts or psychiatric care, 

drug or alcohol abuse, rational thinking loss, organized 

plan or serious attempt, sickness, stated future intent): 

-Current suicide attempt, score >4: 90.4% sensitivity, 

65.6% specificity; PPV 48.8%, NPV 95.0%.

AUC 0.874 (95% CI, 0.85 to 0.89), P<0.001.

5-item risk model (previous attempts or psychiatric 

care, alcohol or drug abuse, stated future intent, age 19-

45 years, rational thinking loss):

-Future suicide attempt, score >1: 93.5% sensitivity, 

27.9% specificity; PPV 3.6%, NPV 99.3%.

AUC 0.665 (95% CI, 0.61 to 0.72), P<0.001.
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Author, 

Year Study Design; Approach N; Population

Risk Assessment 

Method Outcome Measures of Accuracy

Galfalvy,

200840

Case series; used Cox 

proportional hazard regression 

models and stepwise model 

selection procedures to 

determine predictor variables 

and AUC estimates to 

determine optimum cut-points 

to estimate sensitivity and 

specificity.

304 adults with major 

depressive disorder or 

bipolar disorders 

presenting for 

evaluation and 

treatment in the US.

15 candidate predictor 

variables for models 

include age, gender, 

psychiatric diagnosis, 

co-morbid borderline 

personality disorder, 

history of past suicide 

attempt, smoking, and 

baseline scores on 9 

psychosocial scales.* 

Suicide attempts 

within 2 years

based on an indepth assessment 

of suicidal 

behavior.

Model 2 (3 terms: past suicide attempt, smoking status, 

and suicidal ideation score): AUC 0.76. 

-Cut-point 0.5: 27%, sensitivity, 92% specificity.

-Cut-point 0.25: 75% sensitivity, 75% specificity.

Model 4 (40 terms): AUC 0.90.

-Cut-point 0.5: 63% sensitivity, 91% specificity.

-Cut-point 0.25: 71% sensitivity, 80% specificity.

Model 5 (9 terms: past suicide attempt, smoking status, 

age, past attempt X age, male sex, suicidal ideation 

score, hostility score, bipolar diagnosis, bipolar 

diagnosis X hostility score): AUC 0.81.

-Cut-point 0.5: 31% sensitivity, 92% specificity.

-Cut-point 0.25: 71% sensitivity, 77% specificity.

Galynker,

201541

Case series; based on 

exploratory factor analysis on 

questionnaire items associated 

with suicidality; a simplified 9-

item score was calculated as the 

sum of scores for items loading 

above 0.5 on factor 1 minus the 

sum of scores for items loading 

above 0.5 on factor 2. 

91 adult psychiatric 

inpatients admitted for 

suicidal ideation or 

suicide attempt.

Suicide Opinion 

Questionnaire (SOQ), 

a 100-item self-report 

measure.

Suicide attempts 

within 2 months 

of discharge based 

on the Columbia 

Suicide Severity 

Rating Scale (CSSRS). 

20-item model (items found to be statistically 

significant between suicide attempters and nonattempters): AUC 0.944. 

-Optimal cut-point (not reported): 85.7% sensitivity, 

97% specificity. Correctly classified 35/40 (87.5%) of 

participants.

9-item model: AUC 0.861. 

-Cut-point <10: 85.7% sensitivity, 69.7% specificity

Lower Beck Scale for Suicide Ideation scores showed a 

non-significant trend to increased risk of post-discharge 

suicide attempt (AUC 0.650, P=.292). C-SSRS rating of 

suicidal ideation severity showed no relation with postdischarge suicide attempt (AUC 0.521, P=.856).

Kessler,

201542

Case series; used administrative

data from the Historical 

Administrative Data System of 

the Army STARRS and 

machine learning methods 

(regression trees and penalized 

regressions) to develop a risk 

algorithm to predict posthospitalization suicides.

40,820 active duty US 

Army soldiers with 

53,769 psychiatric 

hospitalizations. 

Population-level 

prediction model 

derived from 38 US 

Army and Department 

of Defense 

administrative data 

systems (421 

individual predictor 

variables).

Suicides within 12 

months of hospital 

discharge.

20-predictor model: AUC 0.84

73-predictor model: AUC 0.89

421-predictor model: AUC 0.85
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year Study Design; Approach N; Population

Risk Assessment 

Method Outcome Measures of Accuracy

McCarthy,

201543

Nested, case-control study; 

predictive model derived from

clinical records; included 

patients who died from suicide 

(case patients) and a random 

1% of living patients (control 

patients), divided randomly into 

development and validation 

sets; determined AUC 

estimates.

5,969,662 Veterans 

alive as of September 

2010 and had 

encounters with the 

Veterans Health 

Administration in the 

US in the previous 2 

years. 

Population-level 

prediction model 

derived from Veterans 

Health Administration 

clinical records (381 

total measures 

including 31 

interaction terms). 

Suicide within 12 

months according 

to the National 

Death Index.

AUC 0.761 (95% CI, 0.751 to 0.771).

 

Nock,

201044

Case series; used hierarchical 

logistic regression analysis with 

a step controlling for 

clinician/patient prediction and 

severity of suicide ideation at 

presentation; determined 

sensitivity, specificity, PPV, 

NPV estimates.

157 adults presenting 

to a psychiatric 

emergency department 

in the US with lifetime 

histories of suicide 

attempts at baseline; 91 

patients were included 

in the diagnostic

accuracy analysis.

Scores on the 

Death/suicide Implicit 

Association Test were 

dichotomized 

depending on whether 

a score represented an 

association between 

death/suicide and self 

(score >0) versus life 

and self (score <0).

Suicide attempts 

within 6 months 

assessed by the 

Self-Injurious 

Thoughts and 

Behaviors 

Interview.

Cut-point >0: 50% sensitivity, 81% specificity; PPV 32%, 

NPV 90%.

Rana,

201245

Case series; used 15 machine 

learning algorithms to 

determine accuracy in 

discriminating between patients 

who die by suicide, attempt 

suicide, and never attempt 

suicide; 100 random subsets of 

data were created, classification 

was performed and averaged, 

and sensitivity and specificity 

were calculated.

27,061 risk 

assessments from 

8,739 patients 

receiving care at the 

Mental Health, Drugs 

and Alcohol Services 

at a large public health 

system.

15 separate machine 

learning algorithms to 

examine associations 

between suicide and 

the Barwon Health 

Suicide Risk 

Assessment, an 18-

item clinician-rated 

checklist.

Suicide (death 

certificates and a 

centralized 

registry) or 

suicide attempts 

(emergency 

department ICD 

codes for selfharm).

Sensitivity 35-50%; specificity 65-70%.
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Author, 

Year Study Design; Approach N; Population

Risk Assessment 

Method Outcome Measures of Accuracy

Steeg,

201246

Case series; a clinical screening 

tool was derived using a 

classification tree that used 

binary recursive partitioning to 

split the data, then was tested 

with data from patients at 

another site; determined 

sensitivity, specificity, PPV, 

NPV estimates.

29,571 episodes of 

self-harm by 18,680 

adults aged ≥16 years 

presenting to 

emergency 

departments in 

England (22,532 

episodes derivation set, 

7,039 validation set).

ReACT Self Harm 

Rule, a clinical 

screening tool using 4 

domains. Presentation 

with self-harm was 

classified as either 

low risk or high to 

moderate risk based 

on the presence of one

or more risk factors.

Suicide within 6 

months according 

to the ICD-10 

codes from 

patients’ records 

in national health 

database.

Derivation set: 91% (95% CI, 81% to 97%) sensitivity, 

15% (95% CI, 15% to 16%) specificity; PPV 40% 

(95% CI, 30% to 50%), NPV 99.8% (95% CI, 99.6% to 

99.9%). 

Validation set: 88% (95% CI, 70% to 98%) sensitivity, 

24% (95% CI, 23% to 25%) specificity; PPV 50% 

(95% CI, 30% to 70%), NPV 99.6% (95% CI, 99.5% to 

99.7%).

Correctly predicted 83/92 (90.2%) of suicides occurring 

within 6 months.

Tran,

201447 

Case series; a predictive model 

for 1-6 month risk of suicide 

was derived from data from 

electronic medical records; the 

model was compared to an 

established clinician-rated 

checklist to estimate AUC.

7,399 patients 

undergoing suicide risk 

assessment (4,911 

derivation set, 2488 

validation set).

Risk stratification 

model using data from 

electronic medical 

records was compared 

to the Barwon Health 

Suicide Risk 

Assessment, an 18-

item clinician-rated 

checklist.

Suicide or suicide 

attempts (ICD-10 

self-harm codes of 

high- or 

moderatelethality) within 

180 days of risk 

assessment.

AUC for high-risk; clinician checklist versus electronic 

medical record model: 

30 days: 0.55 (95% CI, 0.44 to 0.67) versus 0.73 (95% 

CI, 0.62 to 0.84).

60 days: 0.59 (95% CI, 0.50 to 0.69) versus 0.79 (95% 

CI, 0.70 to 0.85).

90 days: 0.58 (95% CI, 0.50 to 0.66) versus 0.79 (95% 

CI, 0.72 to 0.84).

180 days: 0.57 (95% CI, 0.49 to 0.63) versus 0.75 (95% 

CI, 0.69 to 0.80).

van 

Spijker, 

201448

Case series; online responses on 

the Suicidal Ideation Attributes 

Scale were compared with a set 

of psychosocial assessments† to 

estimate AUC, sensitivity, and 

specificity.

1,352 adults from the 

general population in 

Australia who were 

recruited online.

Suicidal Ideation 

Attributes Scale, a 5-

item online self-report

measure.

Suicide 

preparation/

attempt in the past 

year based on a 

condensed version 

of the Columbia 

Suicide Severity 

Rating Scale.

Cut-point ≥1 (low ideation): 84.0% sensitivity, 63.6% 

specificity.

Cut-point ≥21 (high ideation): 50% sensitivity, 94.9% 

specificity.

Yaseen,

2012a

50

Case series; correlations 

between suicide attempts and 

the Suicide Trigger Scale were 

calculated using binary logistic 

regression analysis; used AUC 

estimates to determine optimum 

cut-points to estimate sensitivity 

and specificity.

183 adult psychiatric 

patients with suicidal 

ideation or attempts in 

a psychiatric 

emergency department 

in the US.

Suicide Trigger Scale, 

a 42-item self-report

measure.

Current suicide 

attempt and 

attempts within 

the next year 

based on the

Columbia Suicide 

Severity Rating 

Scale.

Current attempt: AUC 0.724, P=.002.

-Cut-point 13: 72.2% sensitivity, 60.5% specificity.

Future attempt: Not calculated because of high loss to 

follow-up.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year Study Design; Approach N; Population

Risk Assessment 

Method Outcome Measures of Accuracy

Yaseen,

2012b49

Case series; derived a 

composite suicide-related 

subscale from items from the 

Affective Intensity Rating 

Scale; determined sensitivity 

and specificity.

176 adult psychiatric 

patients with suicidal 

ideation or attempts in 

a psychiatric 

emergency department 

in the US.

Modification of the 

Affective Intensity 

Rating Scale, a 17-

item self-report

measure.

Current suicide 

attempt based on 

the Columbia 

Suicide Severity 

Rating Scale. 

Cut-point ≥0 overall: AUC 0.768 (95% CI, 0.673 to 

0.864), P<0.0005. 

-86.7% sensitivity, 41.7% specificity.

Cut-point ≥0 for substantive attempts: AUC 0.744, 

P=.010. 

-90.0% sensitivity, 38.4% specificity.

Yaseen,

201451

Case series; transformed scores 

from the Suicide Trigger Scale 

were calculated as the absolute 

value of the total score minus 

the median score; used AUC 

estimates to determine optimum 

cut-points to estimate 

sensitivity, specificity, PPV, 

NPV.

161 adult psychiatric 

patients hospitalized 

following suicidal 

ideation or attempt in 

the US.

Suicide Trigger Scale, 

a 42-item self-report 

measure.

Suicide attempt 

within 6 months 

of discharge based 

on the Columbia 

Suicide Severity 

Rating Scale, US 

national death 

registry, and 

patient medical 

records.

Full scale:

-Cut-point ≥19: 69.2% sensitivity, 68.3% specificity; 

PPV 40.9%, NPV 87.5%; AUC 0.731, P=.013. 

-Correctly classified 37/54 (68.5%) participants. 

6-item subscale (items 2, 4, 7, 23, 27 and 41, median 

score 7): AUC 0.814, P=.001. 

-Cut-point >2: 92.3% sensitivity, 63.4% specificity.

-Cut-point >3: 69.2% sensitivity, 78.0% specificity.

Yen,

201152

Case series; used Cox 

proportional hazards regression 

analyses to determine whether 

baseline scores predicted 

suicide attempts at follow-up;

determined AUC estimates and 

calculated sensitivity, 

specificity, and PPV.

733 adults with a 

personality disorder or 

major depressive 

disorder.

Schedule for 

Nonadaptive and 

Adaptive Personality–

Self-harm Subscale 

(SNAP-SH), a 16-

item subscale of a 

self-report personality 

inventory. 

Suicide or suicide 

attempt within 12 

months based on 

self-reported

behaviors on the 

Longitudinal 

Interval FollowUp Evaluation 

semi-structured 

interview.

AUC 0.855

Cut-point 10: 84% sensitivity, 70% specificity; PPV 

22%.

Cut-point 11: 78% sensitivity, 77% specificity; PPV 

26%.

Cut-point 12: 72% sensitivity, 85% specificity; PPV 

33%.

Studies Included in the Previous Systematic Review2

Breshears,

201033

Case series; used hierarchical 

multiple regression and AUC 

estimates to determine optimum 

cut-points to estimate sensitivity 

and specificity.

154 Veterans with 

traumatic brain injury 

in the US.

Suicide Potential 

Index and Suicidal

Ideation subscales of 

the Personality 

Assessment 

Inventory. 

Suicide and 

suicidal behavior 

(not defined) 

within 2 years of 

assessment.

Suicide Potential Index:

Cut-point ≥15: 90.9% sensitivity, 76.5% specificity; 

AUC 0.903. 

Cut-point ≥15 plus pre-assessment suicidal behavior: 

90.9% sensitivity, 95.1% specificity; 

AUC 0.972.

Cut-point ≥11 plus pre-assessment suicidal behavior: 

100.0% sensitivity, 86.0% specificity.

The Suicidal Ideation subscale scores did not increase 

incremental validity (P=.65, diagnostic accuracy not 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year Study Design; Approach N; Population

Risk Assessment 

Method Outcome Measures of Accuracy

determined).

Hartl,

200534

Case series; used signal 

detection methods and AUC 

estimates to determine optimum 

cut-points to estimate sensitivity 

and specificity.

630 male Veterans 

with a primary 

posttraumatic stress 

disorder (PTSD) 

diagnosis entering a 

residential treatment 

program for PTSD in 

the US.

Beck Depression 

Inventory.

Suicide attempt 

within 4 months 

of discharge.

Beck Depression Inventory ≥46 and suicide attempt in the 

4 months prior to intake: 63% sensitivity, 80% specificity 

in the exploratory sample; 11% sensitivity, 84% 

specificity in the replication sample.

Hendin,

201035

Case series; used AUC 

estimates to determine 

sensitivity and specificity. 

283 in- and outpatients 

at a VA Medical 

Center in the US with 

affective disorder, or 

affective disorder plus 

substance abuse or 

anxiety disorders.

Affective States 

Questionnaire; a 

positive score was 

determined by rating 

at least 3 of the 7 

affects as “severe” or 

“extreme.”

Suicidal 

behavior‡ within 

3 months of 

assessment.

60% sensitivity, 74% specificity; PPV 32%, NPV 90%. 

Tiet,

200636

Case series; a decision tree for 

identifying high-risk patients

was derived from the Addiction

Severity Index and variables 

from VA databases; used AUC 

estimates to determine optimum 

cut-points to estimate sensitivity 

and specificity for 3 models§.

5,671 adults with 

suicidal ideation from a 

national cohort seeking 

substance abuse 

treatment at 150 VA 

Medical Centers in the 

US.

Decision tree included 

significant predictors 

of suicide attempts||. 

Suicide attempts 

in the past 30 days 

assessed with the 

Addiction

Severity Index 

face-to-face 

interview. 

30% model: 33% sensitivity, 87% specificity; PPV 

37%, NPV 85%.

20% model: 72% sensitivity, 63% specificity; PPV 

30%, NPV 90%. 

10% model: 89% sensitivity, 42% specificity; PPV 

25%, NPV 95%. 

Abbreviations: Army STARRS = Army Study to Assess Risk and Resilience in Servicemembers; AUC = area under the receiver-operator characteristic (ROC) curve; 

CI = confidence interval; NPV = negative predictive value; PPV = positive predictive value; PTSD = posttraumatic stress disorder; ROC = receiver-operator 

characteristic (ROC) curve; VA = Veterans Affairs.

* Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Hopelessness Scale, Scale for Suicidal Ideation, Reasons for Living Inventory, Brown Goodwin 

Lifetime Aggression History Scale, Buss-Durkee Hostility Inventory, Barratt Impulsivity Scale, and St. Paul Ramsey Questionnaire.

† Psychological distress, depression, anxiety disorders, alcohol use, sleep problems, suicidal ideation, suicide literacy, suicide stigma, exposure to suicide, interpersonal

risk factors for suicide, and demographic variables.

‡ Attempts, interrupted or aborted attempts, or preparatory acts/behaviors, with some degree of intent to die; or hospitalization/institutionalization.

§ Based on the results of the decision tree, sensitivity and specificity were calculated for 3 hypothetical models using varying cut points of the percentages (10%, 20%, 

and 30%) of patients who attempted suicide in the past 30 days. A model that uses a cut-point at 30% means that the model requires the true-positive rate to be at least a 

30% and that 30% or more of patients are predicted to attempt suicide.

|| Suicide attempt/ideation history, recent alcohol abuse, recent cocaine abuse, violent behavior, hallucinations, and employment status.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 4. Measures Used as Predictors or Outcomes in Studies of Methods to Identify Individuals 

at Risk for Suicide and Other Suicidal Self-directed Violence Included in the Systematic Review

Measure

Abbreviation Items and scoring Description

Included 

Studies Using 

Measure

Addiction 

Severity 

Index53

ASI Computer-generated 

composite scores range 

from 0-1; severity 

ratings based on 

interviewer estimates 

for each of the 7 

subscales range from 0-

9. 

Semi-structured clinical interview designed as part of 

an intake process for substance abuse treatment 

programs. Provides severity ratings and composite 

scores for 7 areas: psychiatric conditions, alcohol use, 

drug use, medical conditions, interpersonal issues, 

employment, and legal problems/functioning 

experienced in the patient’s lifetime and within the 30 

days before assessment. The clinical interview takes 

approximately one hour, must be completed by a 

provider trained in substance abuse treatment, and is not 

appropriate for brief screening or primary care settings.

Tiet 200636

Affective 

Intensity Rating 

Scale49

AIRS 17 items; 3-point scale 

ranges from 0=not at 

all to 2=a lot. 

Self-report scale to measure the degree to which 

positive and negative affects were experienced during 

the 72 hours leading up to psychiatric contact in the 

emergency room.

Yaseen 2012b49

Affective States 

Questionnaire35,

54,55

ASQ 7 items; 5-point scale 

ranges from 1=not at 

all to 5=extreme.

Clinical interview to measure the intensity of 9 affects 

(anxiety, rage, desperation, abandonment, loneliness, 

hopelessness, self-hatred, guilt, and humiliation).

Hendin 201035

Barwon Health 

Suicide Risk 

Assessment56

None 18 items; 3-point scale 

(low/ moderate/high). 

Clinician-rated checklist based on established risk 

factors, including suicidal ideation, suicide plan, access 

to means, prior attempts, anger/hostility/ impulsivity, 

depression (current level), anxiety, disorientation/ 

disorganization, hopelessness, identifiable stressors, 

substance abuse, psychosis, medical status, withdrawal 

from others, expressed communication, psychiatric 

service history, coping strategies, and supportive others 

(connectedness). In addition to the 18 items, clinicians 

provide overall ratings of suicide risk and carers 

provide their perceptions of risk on 4-point scales from 

1 (low) to 4 (extreme).

Rana 201245;

Tran 201447

Beck 

Depression 

Inventory-II57

BDI-II 21 items; 4-point scale; 

scores range from 0-63

Self-report inventory to assess depressive symptoms; is 

brief, easy to administer and score, and often used in 

primary care settings.

Hartl 200534

Columbia 

Classification 

Algorithm of 

Suicide 

Assessment58

C-CASA Not applicable; events 

are categorized into 

one of 8 definitions 

Standardized classification system to accurately classify 

suicidal ideation and behavior into 8 mutually exclusive 

definitions (in main 2 categories, suicidal events and 

non-suicidal events) based on clinical judgment. The 

scale differentiates between suicide attempts with 

intention to die and self-harm behaviors that are not 

intended to result in death. 

Bolton 201239

Columbia 

Suicide 

Severity Rating 

Scale59

C-SSRS Suicide attempt 

lethality: 6-point scale 

(0=no or very minor 

injury requiring no care 

to 5=death). 

Suicidal ideation 

severity: 5-point scale 

(0=no ideation present 

Semi-structured interview to identify suicidal ideation 

and behavior. Assessment of suicidal behavior ranges 

from preparatory acts to suicide attempt (distinguished 

from aborted and interrupted attempts). Four constructs 

are measured: severity of suicidal ideation, intensity of 

suicidal ideation subscale, suicidal behavior subscale, 

and lethality subscale (assesses actual attempts).

Galynker 

201541; 

van Spijker 

201448; 

Yaseen 

2012a

50; 

Yaseen 

2012b49;
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Measure

Abbreviation Items and scoring Description

Included 

Studies Using 

Measure

to 5=active ideation 

with plan and intent).

Yaseen 201451

Death/suicide 

Implicit 

Association 

Test44,60

IAT D score of relative 

strength of association 

between “death” and 

“self” (positive D score 

represents stronger 

association between 

death and self; negative 

D score represents 

stronger association 

between life and self).

Brief computer-administered test that uses individuals’ 

reaction times when classifying semantic stimuli to 

measure the automatic mental associations they hold 

about life and death/suicide. Participants classify 

stimuli representing the constructs of “death” (ie, die, 

dead, deceased, lifeless, and suicide) and “life” (ie, 

alive, survive, live, thrive, and breathing) and the 

attributes of “me” (ie, I, myself, my, mine, and self) and 

“not me” (ie, they, them, their, theirs, and other).

Nock 201044

Longitudinal 

Interval 

Follow-up 

Evaluation61

LIFE Suicidal behavior is 

rated for intent (6-point 

scale from obviously 

no intent to extreme) 

and medical threat (6-

point scale from no 

danger to extreme).

Semi-structured interview rating system for assessing 

the longitudinal course of psychiatric disorders and 

functioning, including suicidal behaviors. Major 

Affective Disorders psychopathology is rated on a 6-

point scale and Chronic Depressive Disorders 

psychopathology is rated on a 3-point scale.

Yen 201152

Modified SAD 

PERSONS62

MSPS 10 items; dichotomous; 

scores range from 0-14.

Simple clinician-assessed checklist of 10 risk factors, 

with some risk factors weighted more heavily than 

others. Items worth 2 points: depression or 

hopelessness, rational thinking loss, organized or 

serious attempt, stated future intent. Items worth 1 

point: male sex, age <19 or >45 years, previous 

attempts or psychiatric care, excessive alcohol or drug 

use, single/divorced/widowed, and no social supports.

Bolton 201239

Personality 

Assessment 

Inventory63

PAI 344 items; 4-point 

scale ranges from 

1=not true at all to 

4=very true

Self-report personality test that includes 4 validity 

scales, 11 clinical scales, 5 treatment scales, and 2 

interpersonal scales. Takes 50-60 minutes to administer 

and 15-20 minutes to score; recommended use is by 

psychologists as part of a comprehensive assessment.

Breshears

201033

ReACT Self 

Harm Rule46

None 4 items; dichotomous

(yes or no). 

Clinical screening tool derived from a classification 

tree. Self-harm is classified as either low or high to 

moderate risk based on the presence of one or more of 

the following risk factors: recent self-harm, lives alone

or is homeless, cutting used as method of self-harm, and 

treatment for a current psychiatric disorder.

Steeg 201246

SAD 

PERSONS64

None 10 items; dichotomous; 

scores range from 0-10.

Simple clinician-assessed checklist consisting of 10 risk 

factors: male sex, age <19 or >45, depression, previous 

attempt, alcohol abuse, rational thinking loss, lacking 

social support, organized plan, no spouse, and sickness.

Bolton 201239

Self-Injurious 

Thoughts and 

Behaviors 

Interview65

SITBI 269 items in 5 

modules; 5-point scale 

ranging from 

0=low/little to 4=very

much/severe. 

Structured interview to identify the presence, frequency, 

and characteristics of self-injurious thoughts and 

behaviors, including suicidal ideation, suicide plans, 

suicide gestures, suicide attempts, and non-suicidal selfinjury. Administration takes approximately 3-15 

minutes.

Nock 201044
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Measure

Abbreviation Items and scoring Description

Included 

Studies Using 

Measure

Sleep Quality 

Index38

SQI 5 items; 3-point scale 

ranges from 1=most of 

the time to 3=none of 

the time; scores range 

from 5-15.

Scale to evaluate sleep quality that includes items 

relating to difficulty falling asleep, difficulty staying 

asleep, early morning awakening, daytime sleepiness, 

and nonrestorative sleep.

Bernert 201438

Suicidal 

Ideation 

Attributes 

Scale48

SIDAS 5 items; 10-point scale. Brief, web-based self-report instrument to measure the 

severity of suicidal ideation. Assessing frequency, 

controllability, closeness to attempt, distress, and 

interference with daily activities over the past month. 

Respondents who report never having suicidal ideation 

on the first item of the scale skip the remaining items 

and are given a total score of 0. The scale generally 

takes between 30 and 60 seconds to complete, although 

shorter for individuals with no suicidal ideation.

van Spijker 

201448

Schedule for 

Nonadaptive 

and Adaptive 

Personality66

SNAP 425 items; true or false. Self-report questionnaire designed to assess both 

normal and abnormal personality characteristics. The 

questions are grouped in to 15 subscales; 3 of the 

subscales are temperament scales that assess broad, 

higher-order domains of normal range personality; the 

other 12 subscales measure lower-order trait 

dimensions. The SNAP-Self-harm (SNAP-SH) subscale 

contains 2 highly related subcomponents: low selfesteem (7 items) and suicide proneness (9 items). The 

low self-esteem scale assesses the tendency for selfloathing or strong self-dissatisfaction. The suicide 

proneness scale assesses self-destructive thoughts and 

behaviors. 

Yen 201152

Suicidal

Ideation scale63

SUI 12 items Subscale of the Personality Assessment Inventory 

encompasses items ranging from passive thoughts of 

death, to hopelessness, to serious contemplation of 

suicide. T-scores of 60 to 69 are typical of clinical 

respondents; scores ≥70 indicate a “significant warning 

sign” of suicide potential.

Breshears 

201033

Suicide 

Opinion 

Questionnaire67,

68

SOQ 100 items; 5-point 

scale ranging from 

1=strongly agree to 5= 

strongly disagree.

Self-report questionnaire measuring beliefs and 

attitudes toward suicide. Each item consists of a

statement regarding an attitude towards suicide. 

Galynker 

201541

Suicide 

Potential 

Index63

SPI 20 items; 1 point is 

assigned for each factor 

for which an 

individual’s T-score 

exceeds a statistically 

derived cut-point; 

scores range from 0-20.

Subscale of the Personality Assessment Inventory that 

includes 20 clinical factors (eg, hopelessness, severe 

anhedonia, social isolation) and other latent variables 

with empirical relationships to suicide risk. 

Breshears 

201033

Suicide Trigger 

Scale50

STS-3 42 items; 3-point scale 

ranges from 0=not at 

all to 2=a lot. 

Self-report measure to assess the distinct panic-like 

syndrome known as the “suicide trigger state,” 

combining frantic hopelessness, ruminative flooding, 

and near-psychotic somatization. The scale does not 

contain questions overtly related to suicide in order to 

avoid over- and under-reporting of suicidal symptoms. 

Yaseen 

2012a

50; 

Yaseen 201451
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

27

Table 5. Quality Ratings of Studies of Methods to Identify Individuals at Risk for Suicide and Other Suicidal Self-directed 

Violence* 

Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

Recently Published Studies

Bernert, 

201438

Yes, main 

characteristics 

described, but 

inclusion 

criteria were 

not reported.

Unclear for 

original cohort 

study 

(N=14,456) 

(CornoniHuntley 

199369). For 

nested casecontrol study, 

control 

participants

were randomly 

selected from 

the cohort.

Unclear, 

N=20 

suicides; 

400 

controls. 

Yes, nested 

case-control 

design only 

included 

participants 

with complete 

data.

Yes, assessments 

were described 

and referenced.

Unclear, not 

reported.

Yes, cause of 

death listed as 

suicide on 

official death 

certificates 

(ICD-9 code 

between 950 and 

959).

Not 

applicable.† 

Yes, 

participants 

matched by 

age, sex, 

study site, and 

duration of 

study, and 

analysis 

controlled for 

baseline 

depressive 

symptoms.

Unclear 

Bolton,

201239

No, 

characteristics 

were not 

described 

(sex only).

Yes, 

consecutive 

adult referrals.

Yes, 

N=4,019; 

566 with 

suicide 

attempts. 

Unclear, not 

reported. 

Yes, 

assessments 

were described 

and referenced.

Unclear, not 

reported.

Yes, presenting 

with suicide 

attempt as 

defined by the 

Columbia 

Classification 

Algorithm of 

Suicide 

Assessment. 

Unclear, not 

reported.

Not 

applicable.‡ 

Unclear

Galfalvy,

200840

Yes Unclear, not 

reported.

No, N=308; 

52 attempts 

and 4 

suicides 

during 

No, 40% lost 

to follow-up; 

analysis 

based on time 

to first suicide

Yes, described 

in a separate 

publication 

(Oquendo 

200470).

Unclear, not 

reported.

Unclear, based 

on an in-depth 

assessment of

suicidal 

behavior, but no 

Unclear, not 

reported.

Not 

applicable.‡ 

Unclear
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

follow-up. attempt 

accounts for 

attrition (data 

for 304/308 

participants).

definition or 

standardized 

method 

described.

Galynker,

201541

Yes No, referred by 

clinician.

No, N=91; 7 

with 

attempts 

within 2 

months 

follow-up. 

No, 56% 

(51/91) lost to 

follow-up.

No, scale was

not administered 

to 25 patients at 

baseline; items 

used for the 9-

item score were 

not reported.

Yes, selfreport 

measure.

Yes, postdischarge 

suicide attempt 

based on the 

Columbia 

Suicide Severity 

Rating Scale.

Unclear, not 

reported.

Not 

applicable.‡ 

High

Kessler,

201542

No, 

population 

characteristics 

not described. 

Yes, included 

all patients with

psychiatric 

hospitalizations 

within the study 

period. 

Yes, N= 

40,820; 68 

suicides. 

Yes, 12-

month 

follow-up not 

available for 

all patients 

due to 

termination of 

military 

service; 

imputation 

used for 

missing data. 

Yes, risk 

prediction model 

described, 

although list of 

predictors used 

for each model 

was not 

provided.

Yes, data 

from existing 

medical 

records.

Unclear, suicide 

data were

extracted from 

administrative 

databases, but 

did not explicitly 

report how 

suicide deaths 

were 

determined.

Not 

applicable.† 

Not 

applicable.‡ 

Low

McCarthy,

201543

Yes Yes, included 

all cases of 

suicide and a 

random 1% 

sample of the 

rest of the 

population as 

controls.

Yes, N=5.9 

million; 

2,138 

suicides.

Unclear, not 

reported.

Yes, risk 

prediction model 

described.

Yes, data 

from existing 

medical 

records.

Yes, suicide 

death according 

to the National 

Death Index.

Not 

applicable.† 

Not 

applicable.‡ 

Low
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

Nock,

201044

Yes Unclear, all 

patients 

presenting with

mental health 

complaints were 

evaluated and

screened for 

eligibility, but 

details not 

reported.

No, N=157; 

43 suicide 

attempts in 

past week. 

Unclear, not 

reported.

Yes, 

assessments 

were described 

and referenced. 

Yes, used a 

computeradministered 

test.

Yes, suicide 

attempt assessed 

by a structured 

interview by 

phone and 

review of 

hospital medical 

records.

Unclear, not 

reported.

Not 

applicable.‡ 

Unclear

Rana,

201245

No, 

characteristics 

were not 

described.

Yes, included 

all risk 

assessments in 

the healthcare 

system database 

within the study 

period.

Unclear, 

27,061 risk 

assessments from 

8,739 

patients; 

number of 

suicides and 

attempts not 

reported.

Unclear, not 

reported.

Yes, machine 

learning 

algorithms were 

described and 

referenced in an 

appendix; risk 

assessment tool 

publicly 

available, 

though scoring 

method is 

unclear.

No, 

assessments 

were 

completed by 

clinicians not 

study staff

according to 

clinical 

guidelines.

Yes, suicide 

deaths 

confirmed with 

death 

certificates; 

suicide attempts 

obtained from 

emergency 

department 

diagnostic 

codes. 

Not 

applicable.† 

Not 

applicable.‡ 

Unclear

Steeg,

201246

Yes, data 

reported in 

separate 

publication.71

Yes, data were 

collected on all 

patients who 

presented with 

self-harm.71

Yes, 

N=18,680; 

92 suicides 

within 6 

months. 

Yes, missing 

data low 

(16% of 

episodes); 

loss to 

follow-up 

may have 

occurred, 

although 

audits 

Unclear, data 

collection 

differed across 

study sites; 68% 

of patient 

presentations 

resulted in 

thorough 

psychosocial 

assessments.

No, 

assessments 

were 

completed by 

clinicians not 

study staff

according to 

clinical 

guidelines.

Yes, death by 

suicide and 

undetermined 

causes according 

to the ICD-10 

codes from 

patients’ records 

in England’s 

national health 

database.§

Not 

applicable.† 

Not 

applicable.‡ 

Low 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

estimated 

minimal loss. 

Tran,

201447 

Yes Yes, included 

all patients 

within study 

period meeting 

inclusion 

criteria based on 

data from 

electronic 

medical records.

Yes, 

N=7,399; 

29 suicides, 

2,208 

attempts. 

Unclear, not 

reported.

Yes, risk 

stratification 

model described, 

and clinician 

risk assessment 

publicly 

available and 

completed for 

each participant 

according to 

hospital policy.

No, 

assessments 

were 

completed by 

clinicians not 

study staff

according to 

clinical 

guidelines.

Unclear, 

diagnostic codes 

for suicide 

attempts varied 

and did not 

necessarily 

represent 

intention to die 

(eg, very high 

blood alcohol 

level).

Not 

applicable.† 

Not 

applicable.‡ 

Unclear

van 

Spijker, 

201448

Yes Yes, all who 

completed the 

online survey 

were included, 

but they may 

not represent 

the general 

population.

No, 

N=1,352; 

13 attempts. 

Yes, no 

follow-up; all 

assessment 

measures 

were 

completed by 

97% of 

participants.

Yes, 

assessments 

were described 

and referenced.

Yes, online 

self-report.

Yes, suicide 

attempt or 

preparations in 

the past year 

were based on a 

condensed 

version of the 

Columbia 

Suicide Severity 

Rating Scale.

Yes, online 

self-report.

Not 

applicable.‡

Unclear

Yaseen,

2012a50

Yes Unclear, clinical 

records were 

reviewed and 

clinical staff 

was approached 

to confirm 

patients’ 

appropriateness 

for the study.

No, N=183; 

55 with

current 

attempts. 

No, 90% 

were lost to 

follow-up.

Yes, risk 

assessment 

described and 

administered 

before other 

assessments in 

order to reduce 

the likelihood of 

biased 

Unclear, not 

reported. 

Yes, current 

suicide attempt 

based on the 

Columbia 

Suicide Severity 

Rating Scale

Unclear, not 

reported.

No, only 

controlled for 

Brief 

Symptom 

Inventory 

subscale 

scores in 

regression 

analysis.

High
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

31

Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

responses.

Yaseen,

2012b49

Yes No, referred by 

clinician.

No, N=176; 

31 with 

current 

attempts. 

Yes, no 

follow-up 

assessment; 

few missing 

data. 

Unclear, some 

patients were 

assessed 

immediately, 

while others 

needing more 

care were 

assessed within 

24 hours of 

stabilization.

Unclear, not 

reported. 

Yes, current 

suicide attempt 

based on the 

Columbia 

Suicide Severity 

Rating Scale.

Unclear, not 

reported.

Unclear, 

controlled for 

some factors 

in regression 

analysis 

(including 

gender, 

diagnostic 

category, and 

substance 

abuse).

High

Yaseen,

201451

Yes No, referred by 

clinician.

No, N=161; 

13 with 

attempts. 

No, 67% lost 

to follow-up. 

Yes, 

assessments 

were described 

and referenced.

Unclear, not 

reported.

Yes, suicide 

attempt based on 

the Columbia 

Suicide Severity 

Rating Scale, US 

national death 

registry, and 

patient medical 

records.

Unclear, not 

reported.

Not 

applicable.‡ 

High 

Yen,

201152

Yes No, recruited 

from study 

clinics.

Yes, 

N=733; 156 

with 

attempts. 

Yes, 14% lost 

to follow-up 

or with 

missing data.

Yes, assessment 

was described 

and referenced.

Yes, selfreport 

measure.

Yes, suicide 

attempt assessed 

by the 

Longitudinal 

Interval Followup Evaluation 

semi-structured 

interview; 

suicide deaths 

confirmed by 

family member 

Unclear, not 

reported.

Not 

applicable.‡ 

Unclear
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

32

Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

and/or death 

certificate.

Studies Included in the Previous Systematic Review2

Breshears,

201033

Yes Unclear, not 

reported.

No, N=154; 

11 with 

suicide 

behavior. 

Unclear, 

included only 

patients with 

medical 

record 

information 

to confirm 

traumatic 

brain injury 

and assess 

injury 

severity.

Unclear, all risk 

factors were 

assessed by 

chart review; 

scoring of the 

Personality 

Assessment 

Inventory was 

likely 

standardized.

Unclear, not 

reported.

No, chart review 

was used as the 

reference 

standard for 

suicidal 

behavior.

Unclear, not 

reported.

Not 

applicable.‡ 

High

Hartl,

200534

Yes Yes, 

consecutive 

admissions.

No, N=630; 

7 with 

attempts 4 

months 

prior to 

intake. 

Unclear, 

missing data 

not reported.

Unclear, intake 

questionnaires 

were not 

described.

Unclear, not 

reported.

Unclear, suicide 

attempt items 

were reportedly 

added to the 

Northeast 

Program 

Evaluation 

Center survey 

and are not 

standard.

Unclear, not 

reported.

Not 

applicable.‡ 

High

Hendin,

201035

Yes Unclear, not 

reported.

No, N=283; 

40 with 

suicidal 

behavior. 

Yes, 240/283 

patients 

completed 

both 

assessments.

Yes, 

assessments 

were described 

and referenced.

Yes, research 

assistant 

assessors 

were 

independent.

Yes, procedures 

were described; 

all patients were 

assessed at 

follow-up.

Unclear, not 

reported.

Not 

applicable.‡ 

Unclear
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year

Adequate 

description 

of 

population?

Non-biased 

selection?

Adequate 

sample size 

for study 

design?

Low loss to 

follow-up/ 

missing 

data?

Standardized 

method of risk 

factor 

assessment and 

scoring clearly 

described or 

referenced?

Unbiased 

risk factor 

assessment 

by 

independent 

assessors?

Adequate 

outcome 

measurement?

Unbiased 

outcome 

measurement 

by 

independent 

assessors?

Adequate 

accounting 

for potential 

confounders

?

Overall 

assessment 

of 

potential 

for bias 

(Low/ 

Unclear/

High)

Tiet,

200636

Yes Unclear, 

recruitment 

time frame not 

described.

Yes, 

N=5,671; 

1,163 with 

attempts 

within 30 

days.

Yes, 2% 

missing data 

(95/5671).

Yes, 

assessments 

were described 

and referenced.

Unclear, not 

reported.

Yes, assessed 

during face-toface interview 

with Addiction

Severity Index.

Unclear, not 

reported. 

Not 

applicable.‡ 

Unclear

Abbreviations: ICD = International Classification of Disease.

* Risk of Bias tool modified from Hayden, 2006 and Harris, 2001.26,28

† Deaths confirmed by reliable external sources (eg, death certificate).

‡ Not relevant to this study.

§ “Undetermined cause” was combined with “suicide” in this study consistent with customary practice in the United Kingdom (UK).
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

34

KEY QUESTION 2: What are the efficacy/effectiveness and adverse 

effects of suicide prevention interventions in reducing rates of suicide 

and other suicidal self-directed violence in Veterans and military 

personnel? Interventions include healthcare services directed 

towards A) populations and B) individuals.

Summary of Findings 

Studies Included in Previous Systematic Reviews

Five previously published systematic reviews included studies of the efficacy or effectiveness of 

suicide prevention interventions in reducing suicide and other suicidal self-directed 

violence,1,3,16,31,32 including 2 previous VA ESP reports of individual3 and population-level 

interventions1 (Table 6). These systematic reviews are provided in this report for context. Only 6 

studies cited in the systematic reviews are relevant to this review because of differences in scope 

and inclusion criteria.72-77 One of these studies is an initial publication of a population-level 

intervention, the Air Force Suicide Prevention Program, that has since been updated.78 This study 

is described in the next section (Table 7). 

Five additional studies cited in the previous systematic reviews provide results of individuallevel interventions (Table 8).72,73,75-77 All are RCTs enrolling non-military and non-Veteran 

populations that compared usual care to individual psychotherapies, including cognitive 

behavioral therapy, dialectical behavior therapy, personal construct psychotherapy, and problemsolving therapy. A trial of 111 women meeting criteria for borderline personality disorder 

compared dialectical behavior therapy with usual care.75 Results indicated fewer suicide attempts 

with the therapy versus usual care at one-year follow-up (23% versus 46%; P = .01). Results of 

the other 4 trials indicated no differences between comparisons; however, they were 

underpowered to detect differences in suicide and suicide attempts,

72,76,77 and were compromised 

by other methodological limitations including unclear or lack of measures of suicidal behavior 

outcomes (Table 9).73
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

35

Table 6. Previous Systematic Reviews of the Efficacy or Effectiveness of Suicide Prevention Interventions in Reducing Suicide 

and Other Suicidal Self-directed Violence

Author, 

Year

Search 

dates Included populations Interventions Suicide-related outcomes Results relevant to the current review

O’Connor,

201315,16

2002-July, 

2012

Adolescents, adults, older 

adults.

Psychotherapy, 

enhanced usual 

care, medication.

Suicide, suicide attempts, 

suicidal ideation, depression.

6 RCTs of psychotherapy reported suicide deaths; 

results were inconclusive.

11 RCTs of psychotherapy suggested reduced suicide 

attempts, but studies were heterogeneous.

13 RCTs of enhanced usual care indicated no 

significant reductions in suicide attempts.

2 RCTs met inclusion criteria for the current review 

and are summarized in Table 8.

O’Neil,

20123§ 

2005-

November, 

2011

Veteran and/or military 

patient subgroups from 

the US, UK, Canada, New 

Zealand, and Australia.

Any intervention 

with the potential to 

reduce or prevent 

suicidal selfdirected violence.* 

Suicidal self-directed violence 

including suicide and suicide 

attempts; did not include

suicidal ideation and 

undetermined or non-suicidal 

self-directed violence.

No RCTs in military or VA healthcare settings. 

5 RCTs of relevant individual-level interventions met 

inclusion criteria for the current review and are 

summarized in Table 8. 

Shekelle,

20091§ 

June, 2005-

May, 2008

Studies reporting results 

from any country for 

military or Veterans were 

included, as were studies 

in Anglo/American 

countries.

System-level 

interventions and 

others except 

strictly mentalhealth 

interventions.

Only studies reporting direct 

effects of interventions on 

suicide and suicide attempts 

were considered.

Insufficient studies of suicide prevention programs 

specifically in Veterans. 

Studies of multicomponent interventions in military 

personnel, psychosocial interventions after suicide 

attempts, and restriction of access to lethal means 

suggest potential effects in reducing risk of suicide. 

Mann,

200531

1966-June, 

2005

Not specified. Various 

interventions to 

reduce suicide.

Suicide and suicide attempts. Physician education in depression recognition and 

treatment as well as restricting access to lethal methods 

reduces suicide rates. Other interventions require more 

evidence of efficacy.†

Gaynes,

200432

1966-

October, 

2002

Primary care patients with 

previously unidentified 

suicide risk.‡

Various 

interventions to 

reduce suicide.

Suicide and suicide attempts. Psychotherapy for suicide prevention can be an effective 

treatment in adults; evidence was limited in older adults 

and adolescents.

Abbreviations: RCT = randomized controlled trial, UK = United Kingdom.

*Includes interventions related to environmental modification, psychotherapy, medication, somatic treatment, and monitoring.

†Includes various types of psychotherapy, post-crisis interventions, and other approaches.

‡Included RCTs were conducted in high-risk groups as identified by a deliberate self-harm episode, diagnosis of borderline personality disorder, or admission to a 

psychiatric unit. Clinical trials targeting patients with chronic psychotic illnesses were excluded.

§Previous VA ESP review on suicide prevention interventions in Veterans and military personnel.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

36

Recently Published Studies

Healthcare Service Interventions Directed Towards Populations

Eight new population-level intervention studies met inclusion criteria (Table 7).78-85 These 

studies evaluated multi-component initiatives implemented within existing organizational 

structures that included military populations,

78,81 police officers,83 college students,82 and 

healthcare systems.79,80,85 The initiatives were comprised of components generally categorized as 

education, awareness, individual health, and individual risk monitoring. One study was designed 

as a retrospective cohort study;80 6 were before-after studies78,79,82-85 and one was a postintervention series81 for which risk of bias criteria were not applicable. All interventions except 

for one82 were designed for primary prevention of suicide. No studies evaluated adverse effects 

of population-level interventions.

The Air Force Suicide Prevention Program is an Air Force-wide intervention that includes policy 

and education initiatives and emphasizes early identification and treatment. Leaders are 

responsible for changing expectations of behaviors to improve suicide prevention awareness. 

Specifically, the program consists of 11 initiatives that are clustered into 7 prevention domains: 

leadership involvement, continuous professional military training, development of guidelines for 

commanders, ongoing community education, development of integrated delivery system and 

community action information boards, enhancement of community mental health services, and 

instituting policies. Implementation began in 1997, and Air Force leaders and installation 

commanders completed surveys and checklists regarding the 11 initiatives twice (2004 and 2006) 

during the 12-year intervention period.78

An initial before-after study of the Air Force Suicide Prevention Program examining suicide 

deaths in the Air Force from 1990 to 2002 found that implementation of the program was 

associated with reduced risk for suicide in a cohort of over 5 million active duty US Air Force 

personnel (relative risk 0.67; 95% CI, 0.57 to 0.80).74 The program was monitored until 2008 and 

long-term outcomes were reported in a subsequent publication.78 The suicide rate before

implementation (estimated per quarter mean from 1981 to 1997) was 3.033 per 100,000 

compared with 2.387 per 100,000 after implementation (from 1997 to 2008) (P<.01). 

A post-intervention series study reported outcomes of a suicide prevention program implemented 

in an Army Infantry Division deployed to Iraq.81 The program integrated specific efforts at each 

phase of deployment, including education, early detection, intervention, communication, 

command/leader emphasis, and treatment for all unit members and their significant others. The 

15-month deployment rate of suicide was compared to the average theater rate and the current 

US Army rate. While the rate for the intervention unit was lower than either of these comparison 

populations (16.0 per 100,000 versus 24.0 per 100,000 for service members in theater and 19.2

per 100,000 for US Army specifically), comparative statistics were not provided. Since the 

suicide rate was compared to that of all deployed forces, there were no specific comparisons with 

usual care or other types of prevention/intervention programs. 

A before-after study evaluated results of the Together for Life suicide prevention program for 

4,178 police officers in Montreal, Quebec, Canada.

83 The program consisted of education, police 

resources, and training for supervisors and union representatives. A half-day training was given 

to all police personnel about the nature of suicide, how to identify suicide risk, and the process of 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

37

helping a colleague in difficulty. In addition, a telephone helpline was created for police officers, 

and a publicity campaign was promoted by internal police newspapers, posters, and brochures.

During the 11 years before the program began (1986 to 1996), the rate of suicide for Montreal 

police officers (30.5 per 100,000 per year; 14 total suicides) was higher than the rate for Quebec 

police forces (26.0 per 100,000). In the 12 years after the program was implemented (1997 to 

2008), the suicide rate for Montreal police officers decreased to 6.4 per 100,000 (4 total suicides; 

pre- versus post-intervention P = .008), while the rate for Quebec police forces increased slightly 

(29.0 per 100,000).

Three studies evaluated population-level interventions implemented in healthcare settings.79,80,85

A before-after study examined outcomes from the Perfect Depression Care initiative, which was 

based on the 6 aims and 10 rules from the Institute of Medicine report Crossing the Quality 

Chasm.

86,87 The Perfect Depression Care initiative was implemented by the Henry Ford Health 

System, a large health maintenance organization in the US.79 The main aim of this initiative was 

to eliminate suicide by emphasizing aspects of high quality care for depression, such as patient 

partnership, access to care, and continually implementing and assessing measures of care quality. 

Methodological procedures and outcome measures were not described. Suicide rates decreased 

from 89 per 100,000 at baseline to 22 per 100,000 after implementation (P = .007). 

A retrospective cohort study evaluated the long-term impact of a program of specialized early 

psychosis treatment on suicidal behaviors among 7,760 young adults with psychotic disorders in 

Australia.80 Patients who received care at a specialized early psychosis program clinic between 

1991 and 1999 (N = 1141) were compared to patients who received care at non-specialist adult 

public mental health services (N = 6619) during the same time period. Data were collected 

retrospectively from the Victorian Psychiatric Case Register. Specialized treatment at the Early 

Psychosis Prevention and Intervention Centre88 consisted primarily of inpatient care lasting up to 

24 months with a minimum of 6 days, and follow-up community-based services. A total of 154 

suicide deaths were recorded over the 8.5-year period, and suicide rates did not differ between 

the program and usual care (P = .84). Cumulative suicide rates progressively increased after 

initial treatment for the entire cohort (one-year 0.7%, 3-year 1.5%, 5-year 2.3%). The study had 

unclear risk of bias; limitations included incomplete consideration of potential confounders 

leading to questionable comparability of intervention and usual care groups, and lack of details 

regarding treatment with usual care.

A before-after study evaluated the implementation of mental health service recommendations 

from the English Suicide Prevention Strategy.85,89 This study was designed to examine the 

relationship between provision of mental health services and national suicide rates, as well as to 

determine the number of recommendations implemented.85 In England and Wales from 1997 to 

2006, 9 key service recommendations were observed, including removing ligature points on 

inpatient wards; assertive outreach; 24-hour crisis team care; follow-up after psychiatric 

discharge within 7 days; a written policy on response to patients non-compliant with treatment; a 

written policy on management of patients with dual diagnoses; criminal justice sharing; 

multidisciplinary review and sharing information with families after suicide; and clinical training 

for staff about suicide risk. Rates were expressed as the number of suicides per 10,000 

individuals per year. Mental health services that provided 24-hour crisis care had the largest 

decline in suicide rates, from 11.44 per 10,000 (95% CI, 11.12 to 11.77) before implementation 

to 9.32 per 10,000 (95% CI, 8.99 to 9.67) after implementation (P<.0001). Suicide rates were 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

38

also lower for establishment of local policies on patients with dual diagnoses (10.55 [95% CI, 

10.23 to 11.88] versus 9.61 [95% CI, 9.18 to 10.05]; P = .0007); and multidisciplinary reviews 

after suicide (11.59 [95% CI, 11.31 to 11.88] versus 10.48 [95% CI, 10.13 to 10.84]; P<.0001).

The effectiveness of the Garrett Lee Smith Youth Suicide Prevention Program, implemented in

over 3,000 US counties, was evaluated in an ecological comparison study.

84 The program 

included education, gatekeeper training, screening activities, improvements in linkages to 

services, crisis hotlines, and community partnerships for US state, territory, tribal, and college 

settings.90 The program allowed site-specific data collection, management, analysis, 

interpretation, and reporting, but had some degree of uniformity of process and outcome 

measurements at nearly all sites. From 2007 to 2010, suicide rates in 479 counties that 

implemented one aspect of the program, gatekeeper training sessions, were compared with rates 

in matching counties with no training.84 Results indicated no statistically significant differences 

for adults ages 19 years and older.

A secondary prevention before-after study examined the effects of mandated treatment after 

suicidal threats or attempts for students at the University of Illinois.

82 The program consisted of 4 

treatment sessions that began within a week of the attempt or threat or after discharge from the 

hospital. These included an assessment of current suicidal risk by mental health professionals; 

working with the student to observe the circumstances of the event; determining lifetime history 

of suicidality and its origins; and drawing attention to the school’s standards of self-welfare and 

the consequences of not adhering to them. Student suicide rates decreased from 6.91 per 100,000

in the 6 years prior to program implementation (1976 to 1983) to 3.78 per 100,000 during the 

first 21 years of the program (1984 to 2005). 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 7. Studies of Population-level Healthcare Service Interventions for Suicide Prevention

Author, 

Year Study Design N; Population Intervention Outcome Results

Recently Published Studies

Coffey,

200779

Before-after 

study

General mental health and 

substance abuse patients 

in a US healthcare 

system; baseline year 

2000, follow-up years 

2002-2005.

Henry Ford Health System’s Perfect Depression Care initiative 

utilized 6 aims and 10 rules from the Institute of Medicine 

report: Crossing the Quality Chasm.86,87

Suicide Suicide rate: 89/100,000 baseline 

versus 22/100,000 follow-up average 

(P=.007); 77/100,000 initially versus 

22/100,000 follow-up average 

(P=.022).

Harris,

200880

Retrospective 

cohort

7,760 patients (ages 15-29 

years) with psychotic 

disorder receiving mental 

health services in 

Victoria, Australia; 59.7% 

male; from 1991-1999.

The Early Psychosis Program involved inpatient specialized 

care at the Early Psychosis Prevention and Intervention Center 

for a period of up to 24 months.88 All patients receiving care in 

the program were compared to patients receiving non-specialist 

adult mental healthcare from other clinics in the area.

Suicide Across 8.5 years, suicide rate: 3.8% 

intervention versus 4.2% usual care 

(P=.84).

Joffe, 

200882

Before-after 

study

College students at the 

University of Illinois and 

citizens of Champaign 

county from 1984-2005. 

Secondary prevention intervention that mandated students with 

suicide attempts or threats to receive 4 professional treatment

sessions conducted by mental health professionals. Failure to 

comply resulted in sanctions. 

Suicide Suicide rate: 6.91/100,000 preintervention versus 3.78/100,000 

post-intervention after 21 years of the 

program. 

Knox,

201078* 

Before-after 

study

>5 million service 

personnel in the US Air 

Force; 1981-2008.

11-component initiative implemented starting in 1997: 

leadership involvement, suicide prevention education, 

commander guidelines for use of mental health services, 

community prevention services, community education and 

training, investigative interview policy, trauma stress response, 

integrated delivery system and community action information 

board, limited privilege suicide prevention program (increased 

confidentiality), assessment, and suicide event surveillance.

Suicide Mean quarterly suicide rate: 

3.033/100,000 pre-intervention 

versus 2.387/100,000 postintervention (P<.01).

Mishara, 

201283

Before-after 

study

4,178 members of the 

Montreal police; Quebec, 

Canada; 1997-2008.

The Together for Life Suicide Prevention Program consisted of 

education, police resources, training for supervisors and union 

representatives, and a publicity campaign.

Suicide Suicide rate: 30.5/100,000 pre 

intervention versus 6.4/100,000 postintervention (P=.008).

Walrath, 

201584

Ecological 

comparison

study

Youths and adults in 479 

counties across the US; 

2007-2010.

The Garrett Lee Smith Youth Suicide Prevention Program 

consisted of education, gatekeeper training, screening activities, 

improvement of linkages to services, crisis hotlines, and 

community partnerships. The study compares counties that 

implemented gatekeeper training with matched counties without 

training. 

Suicide At one and 2 years after training, no 

differences for adults ages 19 and 

older.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year Study Design N; Population Intervention Outcome Results

Warner,

201181

Post 

intervention 

series

40,283 in US deployed 

military unit; 15 months 

in Iraq (March 2007-May 

2008).

Multiple component intervention for deployed unit included:

Pre-Deployment Phase: suicide risk recognition and response 

training, early identification, and resiliency training for 

soldiers and families. 

Deployment: education, suicide prevention review board and 

suicide risk management teams, unit behavioral health needs 

assessment, unit behavioral health advocates, incident 

response, and trend monitoring. 

Re-Deployment: education, post deployment health 

assessment, and risk stratification. 

Reintegration: complete redeployment tasks, prepare for 

reuniting with families, address post-deployment health 

issues.

Suicide Suicide rate: 16.0/100,000 

intervention unit during the 

deployment cycle versus 

24.0/100,000 for service members in 

theater and 19.2/100,000 for US 

Army specifically. 

While, 

201285

Before-after 

study

12,881 suicide deaths 

within mental health 

services in Wales and 

England from 1997-2006. 

Assessed 9 of the 12 key service recommendations from the 

English Suicide Prevention Strategy: removing ligature points 

on inpatient wards, assertive outreach, 24-hour crisis team, 

follow-up after psychiatric discharge within 7 days, written

policy on response to patients non-compliant with treatment, 

written policy on management of patients with dual diagnoses, 

criminal justice sharing, multidisciplinary review and sharing 

information with families after suicide, and clinical training 

around suicide risk for staff.

Suicide Suicide rates that declined preversus post-intervention (per 10,000 

per year): 24-hr crisis care 11.44 

versus 9.32 (P<.0001); 

multidisciplinary review 11.51 

versus 11.39 (P<.0001); dual 

diagnoses 10.51 versus 9.61

(P=.0007). 

Studies Included in the Previous Systematic Review1

Knox,

200374

Before-after 

study

>5 million service 

personnel in the US Air 

Force; 1981-2008.

11-component initiative implemented starting in 1997: 

leadership involvement, suicide prevention education, 

commander guidelines for use of mental health services, 

community prevention services, community education and 

training, investigative interview policy, trauma stress response, 

integrated delivery system and community action information 

board, limited privilege suicide prevention program (increased 

confidentiality), assessment, and suicide event surveillance.

Suicide Suicide relative risk pre- versus postimplementation: 0.67 (95% CI, 0.57 

to 0.80).

Abbreviations: CI = confidence interval.

*Update of Knox 2003.74
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Healthcare Service Interventions Directed Towards Individuals

Five new RCTs of individual-level interventions met inclusion criteria (Table 8).91-95 Trials 

enrolled outpatient military personnel93 and psychiatric inpatients or patients at acute risk for 

suicide;91,92,94,95 no studies enrolled Veterans specifically. Suicide attempt was the main outcome 

in trials of military personnel93 and adults with borderline personality disorder,

95 while suicide 

was the main outcome in the other trials. However, very few suicides occurred and most trials 

were underpowered to detect meaningful differences between groups. No studies evaluated 

adverse effects of individual-level interventions.

A brief cognitive behavioral therapy program was compared with treatment as usual in a trial of 

outpatient active-duty soldiers with recent suicide attempts or ideation.93 Treatment as usual 

consisted of individual and group psychotherapy and psychiatric medication. Participants 

randomized to cognitive behavioral therapy received usual care plus 12 individual outpatient 

psychotherapy sessions. These focused on detailed assessment of the participant’s most recent 

suicidal episode or suicide attempt, cognitive strategies to reduce beliefs and assumptions that 

may exacerbate suicidal behaviors, and relapse prevention. Participants receiving therapy were 

less likely to make suicide attempts during the 2-year follow-up period than those receiving usual 

care (13.8% versus 40.2%, P = .02; hazard ratio 0.38 [95% CI, 0.16 to 0.87]). These results are 

consistent with earlier studies that found that cognitive therapy was effective in reducing suicide 

re-attempt rates compared to usual care.31 The study had unclear risk of bias; limitations included 

inadequate information regarding allocation concealment and blinding and possible selective 

outcome reporting.

Two studies evaluated the effectiveness of dialectical behavior therapy on suicide attempts.

94,95

In one trial, 99 women with borderline personality disorder were randomly assigned to one of 3 

different variations of dialectical behavior therapy.

94 All participants had 2 or more suicide 

attempts or non-suicidal self-injurious acts within the previous 5 years. Standard dialectical 

behavior therapy consisted of weekly individual therapy and group skills training, a therapist 

consultation team, and as-needed between session telephone coaching. The second treatment 

group replaced individual therapy with case management, while the third treatment group 

replaced skills training with an activity-based support group. Results indicated no statistically 

significant differences in occurrence of suicide or suicide attempts between the different types of 

dialectical behavior therapy. The study had unclear risk of bias; allocation concealment was not 

described, dropout rates differed between comparison groups, and the trial was underpowered to 

detect differences.

In another trial, 180 adults with borderline personality disorder were randomly assigned to 

dialectical behavior therapy or general psychiatric management consisting of psychodynamic 

psychotherapy, case management, and pharmacotherapy.

95 Participants were treated for one year

and followed for another 2 years. Suicide attempts did not differ between comparison groups (P

= .83). The study had unclear risk of bias; many participants received treatment during follow-up 

assessment phases and the trial was underpowered to detect differences.

A trial of patients admitted to the emergency department and psychiatric service who had 

engaged in self-harm during the previous 3 days compared a problem-solving skills training 

program with treatment as usual.92 Usual care consisted of assessments by mental health 

professionals and referrals to crisis nurse services and other mental health services (eg,
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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community-based services, pharmacological treatment). In addition to usual care, participants 

randomized to the intervention received six 2-hour weekly closed group sessions focusing on 

interpersonal problem-solving skills training. Suicides were identified by hospital record review 

during a one-year follow-up period. Three participants (2 receiving usual care and one receiving 

problem-solving training) died by suicide; no other statistical data were provided for suicide 

attempts. The study had high risk of bias; limitations included unclear information regarding 

blinding, high differential dropout rates, and no centralized mechanism for identifying cases of 

suicide. The trial was also underpowered to determine differences between comparison groups.

The effectiveness of day hospital treatment versus conventional inpatient treatment in patients 

admitted to psychiatric wards was evaluated in an RCT in the UK.91 Day hospital treatment 

emphasized intensive group programs comprised of work-based activities, creative activities, art 

therapy, psychoeducation, cognitively-oriented problem-solving groups, and psychodynamicallyoriented talking groups. Participants in the day program were expected to attend 35 hours per 

week with optional drop-in service on the weekends. The inpatient ward provided conventional 

psychiatric care with optional daily activities. There were 2 recorded suicide deaths (1 from each 

comparison group) within one year of discharge from treatment; no additional statistical data 

were provided. The study had high risk of bias; limitations included lack of information 

regarding randomization, allocation concealment, blinding, and outcome reporting. The trial was 

also underpowered to determine differences between comparison groups.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 8. Randomized Controlled Trials of Individual-level Healthcare Service Interventions for Suicide Prevention

Author, 

Year N; Population Intervention and Comparison Outcome Results

Recently Published Studies

Jones, 200891 206 patients admitted to 

an adult psychiatric ward 

from 1999-2002 (51.5% 

female); London, UK.

Day hospital: attendance expected 9:30 am to 4:30 pm with optional 

drop-in service on weekends; emphasis on group activities.

Inpatient: conventional psychiatric care; limited program of daily 

activities. 

Suicide 1 suicide in the day hospital 

group versus 1 in the inpatient 

group at 12-months post 

discharge follow-up.

Linehan, 

201594

99 adult women with 

borderline personality 

disorder with at least 2 

suicide attempts or nonsuicidal self-injury acts 

within 5 years from 

2004-2010; Seattle, WA

Standard dialectical behavior therapy: weekly individual therapy and 

group skills training, a therapist consultation team, and as needed 

between session telephone coaching. 

Dialectical behavior therapy with skills training: provided group skills 

training; removed individual component and replaced it with case 

management.

Dialectical behavior therapy with individual therapy: eliminated all 

skills training and added an activity-based support group. 

Suicide and 

suicide 

attempts

1 suicide; no differences in 

suicide attempts.

McAuliffe,

201492

433 psychiatric patients 

ages 18-64 years (65% 

female) in emergency or 

inpatient units who 

reported self-harm within 

past 3 days; Ireland.

Problem-solving skills training: six 2-hour sessions of manualized 

interpersonal problem-solving skills training.

Usual care: assessment and mental health or crisis services referral. 

Suicide 1 suicide in problem-solving 

skills training versus 2 in usual 

care at 12-months follow-up.

McMain, 

201295

180 adults with 

borderline personality 

disorder; Toronto, 

Canada

Dialectical behavior therapy: comprehensive multicomponent 

intervention for individuals with high suicide risk. Contains 4 weekly 

components; individual therapy, group skills training, therapist 

consultation, and as-needed between-session telephone coaches for 

one year. 

General psychiatric management: psychodynamic psychotherapy, 

case management, and pharmacotherapy for one year.

Suicide 

attempts

At 36-months follow-up, no 

differences between comparisons 

(P=.83). 

Rudd, 201593 152 active duty Army 

(87.5% male); Fort 

Carson, Colorado, US.

Brief outpatient cognitive behavioral therapy: 12 sessions, 1-2 weeks 

apart; first session 90 minutes, following sessions 60 minutes; 3 

phases included assessment, cognitive strategies to reduce beliefs and 

assumptions that serve suicidal thoughts, and relapse prevention.

Usual care: treatment as usual.

Suicide and 

Suicide 

Attempt 

Self-Injury 

Interview96

After 2 years follow-up, at least 

one suicide attempt by 8 

individuals in therapy versus 18 

in usual care (14% versus 40%, 

P=.02); multivariate Cox 

regression controlled for baseline 

risk (hazard ratio 0.31, 95% CI, 

0.13 to 0.75).
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year N; Population Intervention and Comparison Outcome Results

Studies Included in the Previous Systematic Review3

Comtois,

201172

32 adults ages 19-62 

years (62% female) with 

recent suicide attempt or 

imminent risk; US.

Collaborative Assessment and Management of Suicidality (CAMS): 

patients identify the causes of suicidal ideation and the reduction in 

suicidal ideation and behavior as a coping strategy; 4-12, 50-60 

minute sessions with CAMS clinicians.

Enhanced usual care: intake with psychiatrist, 1-11 visits with case 

manager, and medication management as needed.

Suicide 

attempts 

and SelfInjury 

Count 

score97

Suicide attempts/self-inflicted 

injuries at 12 months follow-up: 

1.2 (SD 3.9) CAMS versus 3.3 

(SD 7.6) enhanced usual care.

Gallo, 2007;

73

Alexopoulos, 

200998

599 adults age ≥60 years 

(71.6% female) and 

score >20 on the Centers 

for Epidemiologic 

Studies Depression scale.

Intervention: on-site depression care manager working with primary 

care physicians to provide algorithm-based care.

Usual care: educational sessions for primary care physicians and 

notification of patients’ depression, but no specific recommendations 

for individual patients except for psychiatric emergencies.

Suicide Number of suicides at 2-year 

follow-up; number/1000 personyears: 1; 0.7 (95% CI, 0.0 to 4.2) 

intervention versus 0; 0.0 (95% 

CI, 0.0 to 3.3) usual care.

Suicide attempts at 2-year followup: 2 intervention versus 3 usual 

care.

Linehan,

200675

111 women ages 18-45 

years with borderline 

personality disorder and 

current and past suicidal 

behaviors.* 

Dialectical behavior therapy: cognitive behavioral treatment for 

suicidal women meeting criteria for borderline personality disorder; 

targets suicidal behavior, behaviors interfering with treatment 

delivery, and other severe behaviors for one year.

Community treatment by experts: usual care; treatment provided was 

uncontrolled by the research team.

Suicide 

attempts 

and Suicide 

Attempt 

Self-Injury 

Interview96

Suicide attempts: 23% dialectical 

behavior therapy versus 46% 

community treatment by experts

(P=.01; hazard ratio, 2.66, 

P=.005).

Stewart,

200976

32 adults ages 20-58 

years (53% female) 

receiving inpatient 

treatment for suicide 

attempts.

Cognitive behavioral therapy: seven, 1-hour sessions.

Problem-solving therapy: four, 1-hour sessions.

Treatment as usual: usual care provided by the local hospital.

Repeated 

suicide 

attempts 

Average number of suicide 

attempts: cognitive behavioral 

therapy 0.22 (SD 0.64) versus 

usual care 0.22 (SD 0.50) 

(P=NS); problem-solving therapy 

0.33 (SD 0.63) versus usual care 

0.22 (SD 0.50) (P=NS).

Winter,

200777

64 adults (53% female) 

receiving emergency 

care following self-harm.

Personal construct psychotherapy: 2-22 sessions (mean 10.38); 

therapeutic techniques appropriate to particular personal construct 

formulations of the patient’s self-harm were set out in a brief manual.

Usual care: assessment and possible follow-up appointments with a 

mental health team.

Suicide 1 suicide with therapy versus 2 

with usual care.

Abbreviations: CAMS = Collaborative Assessment and Management of Suicidality; CI = confidence interval; NS = not statistically significant; RCT = randomized 

controlled trial; SD = standard deviation.

*2 suicide attempts or self-injuries within the past 5 years, with one in past 8 weeks. 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 9. Quality Ratings of Randomized Controlled Trials of Healthcare Service Interventions for Suicide Prevention*

Author, 

Year

Sequence 

Generation: 

Was the 

allocation 

sequence 

adequately 

generated?

Allocation 

concealment:

Was allocation 

adequately 

concealed?

Blinding: 

Was knowledge of 

the allocated 

intervention 

adequately 

prevented during 

the study?

Incomplete outcome data: 

Were incomplete outcome 

data adequately addressed?

Selective outcome 

reporting: 

Are reports of the 

study free of 

suggestion of 

selective outcome 

reporting?

Other sources of bias: 

Was the study apparently 

free of other problems 

that could put it at a high 

risk of bias?

Overall 

assessment of 

potential for bias:

Low/Unclear/High

Recently Published Studies

Jones,

200891

Unclear, method 

not described.

Unclear, method 

not described.

Unclear, no 

information on 

blinding.

Unclear, not reported. Yes, no omissions of 

expected suiciderelated outcomes.

No, study underpowered 

to determine differences 

between comparisons.

High 

Linehan,

201594

Yes, 

computerized 

adaptive 

randomization 

procedure.

Unclear, method 

not described.

Assessors: Yes.

Participants and 

providers: No.

Yes; no differences

between groups in loss to 

follow-up (18% versus 

33% versus 27%, P>.15);

although time to treatment 

dropout varied (P=.03).

No, rates of suicide 

attempts were not 

reported (only 

reported that no 

significant 

differences between 

groups were found).

Unclear, study 

underpowered to 

determine differences 

between comparisons.

Unclear

McAuliffe,

201492

Yes, computergenerated 

sequence of 

numbers. 

Yes, allocation 

was concealed 

using sealed 

opaque 

envelopes.

Assessors: Yes.

Participants and 

providers: Unclear.

No, high differential 

dropout rates; participants 

who failed to attend the 6-

week follow-up had 

significantly higher levels 

of anxiety at baseline, 

suggesting that they may 

have been more impaired at 

follow-up.

Yes, no omissions of 

expected suiciderelated outcomes.

No, no centralized 

mechanism for 

identifying cases of 

suicide and study 

underpowered to 

determine differences 

between comparisons.

High 

McMain,

201295

Yes, pregenerated block 

randomization 

scheme.99

Yes, statistician 

concealed 

allocation in 

sealed envelopes.

Assessors: Yes.

Participants and 

providers: Unclear.

Yes, no statistically 

significant difference 

between groups in loss to 

follow-up (20% versus 

13%); participants with 

partially missing data were 

included in the analyses 

using mixed-effects growth 

curve models.

Yes, no omissions of 

expected suiciderelated outcomes; 

searched patients lost 

to follow-up in the 

Ontario death registry 

to determine if they 

had died by suicide.

Unclear, many 

participants received 

treatment during followup assessment phases 

and the trial was 

underpowered to detect 

differences between 

comparisons. 

Unclear
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year

Sequence 

Generation: 

Was the 

allocation 

sequence 

adequately 

generated?

Allocation 

concealment:

Was allocation 

adequately 

concealed?

Blinding: 

Was knowledge of 

the allocated 

intervention 

adequately 

prevented during 

the study?

Incomplete outcome data: 

Were incomplete outcome 

data adequately addressed?

Selective outcome 

reporting: 

Are reports of the 

study free of 

suggestion of 

selective outcome 

reporting?

Other sources of bias: 

Was the study apparently 

free of other problems 

that could put it at a high 

risk of bias?

Overall 

assessment of 

potential for bias:

Low/Unclear/High

Rudd,

201593

Yes, 

computerized 

randomization 

program.

Unclear, 

computer 

program was 

used for 

randomization, 

but unclear if 

allocation was 

concealed until 

enrollment 

complete.

Assessors: Yes.

Participants and 

providers: Unclear.

Yes, analysis of missing 

data patterns indicated that 

self-report data were 

missing completely at 

random for both treatment 

conditions; missing data 

handled with maximum 

likelihood estimation and 

multiple imputation of 10 

data sets. 

Unclear, only selfreport data from 

baseline to the 18-

month follow-up 

assessment were used 

in analyses because 

of higher than 

planned attrition rate 

during later follow-up 

assessments.

Yes, none noted. Unclear

Studies Included in the Previous Systematic Review3

Comtois,

201172

Yes, 

minimization 

algorithm 

matching several 

patient 

characteristics.

Unclear, no 

information 

provided.

Assessors: Yes.

Participants and 

providers: Unclear. 

No, 75% of treatment and 

62.5% of control 

participants did not 

complete study.

Yes, no omissions of 

expected suiciderelated outcomes.

No, 2 severe and 

complex patients 

removed from treatment

group; 1 control 

participant removed. No 

demographic or outcome 

data reported for 

completers versus 

noncompleters.

High

Gallo,

200773

Yes, matched 

pairs 

randomized by 

coin flip.

Yes, coin flip 

randomization 

done at the 

clinical practice 

level, so no 

allocation 

concealment 

related to 

patients was 

needed.

Unclear, no 

information on 

blinding.

Yes, attritions and 

exclusions adequately 

documented; 2% excluded 

due to insufficient baseline 

data, and vital statistics 

available on others.

Yes, no omissions of 

expected suiciderelated outcomes. 

Unclear, suicidal 

ideation higher in 

patients with 

intervention at baseline.

Unclear
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Author, 

Year

Sequence 

Generation: 

Was the 

allocation 

sequence 

adequately 

generated?

Allocation 

concealment:

Was allocation 

adequately 

concealed?

Blinding: 

Was knowledge of 

the allocated 

intervention 

adequately 

prevented during 

the study?

Incomplete outcome data: 

Were incomplete outcome 

data adequately addressed?

Selective outcome 

reporting: 

Are reports of the 

study free of 

suggestion of 

selective outcome 

reporting?

Other sources of bias: 

Was the study apparently 

free of other problems 

that could put it at a high 

risk of bias?

Overall 

assessment of 

potential for bias:

Low/Unclear/High

Linehan,

200675

Yes, 

computerized 

adaptive 

minimization 

randomization 

procedure, 

eligible subjects 

were matched to 

treatment 

condition on 5 

primary 

diagnostic 

variables.

Unclear, study 

coordinator was 

not blinded, but 

executed the 

randomization 

program and 

collected all the 

data related to 

treatment.

Assessors: Yes.

Participants and 

providers: No. 

Yes, a pattern-mixture 

analysis was implemented 

using 2-tailed tests.

Attritions and exclusions 

clearly documented and 

accounted for in analyses.

Yes, no omissions of 

any expected suiciderelated outcomes.

Unclear, differences in 

amount of therapy 

received; statistical 

analysis accounted for 

nested data structures.

Unclear

Stewart,

200976

Unclear, method 

not described.

Unclear, method 

not described.

Unclear, no 

information on 

blinding. 

No, high and differential 

attrition (34.4%, 37.5%, 

and 26.1%) across groups. 

Numbers included versus 

analyzed are not clear; one

outlier was eliminated 

before data analysis.

Unclear, not reported. Yes, none noted. High

Winter,

200777

No, not 

randomized: 

participants were 

allocated to the 

psychotherapy 

condition if there 

was a vacancy or 

to the normal 

clinical practice 

condition if not.

No, not 

concealed.

No, does not 

appear to be 

blinded (medical 

records were 

monitored for 

repeat episodes of 

self-harm).

No, very high and 

differential attrition: 64 

allocated, 45% control and 

92% intervention 

completed post-treatment 

assessment; 28% and 54% 

completed 6-month 

assessment. Repetition of 

self-harm behavior was 

traced for all over 3 years.

Yes, no omissions of 

expected suiciderelated outcomes.

No, differences at 

baseline in 2 of 10 

personal construct 

categories of self-harm.

High

*Risk of Bias tool from the Cochrane Collaboration.25
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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KEY QUESTION 3: What are important areas of ongoing research and 

current evidence gaps in research on suicide prevention in Veterans 

and military personnel, and how could they be addressed by future 

research?

Methods to Identify Suicide Risk

Fifteen recent studies and 4 previously published studies on the accuracy of methods to identify 

individuals at increased risk for suicide and other suicidal self-directed violence met inclusion 

criteria for this review. Although these studies provide valuable contributions to an expanding 

evidence base, important gaps remain. In addition, no studies evaluated the adverse effects of 

risk assessment methods or compared how accuracy and adverse effects vary by settings, 

delivery modes, targeted populations, or other factors.

Previous systematic reviews of suicide risk assessment methods have almost invariably resulted 

in lists of scales or checklists containing self-report items that are summed and scored. The 

current systematic review casts a wider net, allowing inclusion of other methods of risk 

assessment.

42-47 Despite this newer work, validation of many risk assessment methods is still 

needed, and applications to practice are still exploratory. None of the published studies would be 

considered definitive for patient care, and the best risk assessment method for clinical practice 

remains uncertain.

Among studies of suicide risk assessment methods, specific instruments were rarely examined in 

multiple studies. This pattern of one-off examination of instruments was also observed in studies 

of the many instruments that were not eligible for inclusion in the current systematic review, 

including the Suicide Cognitions Scale,

100 Brief Symptom Inventory,101 Holmes-Rahe Social 

Readjustment Scale,

102 Suicidal History Self-Rating Screening Scale,103 Risk Assessment 

Suicidality Scale,104 and numerous others. Studies of these instruments were not included for 

various reasons including enrollment of participants not relevant to Veterans and military 

personnel, lack of reporting of accuracy measures, and other exclusions detailed in Appendices

B and E.

Also, new studies of previously developed methods, such as the Columbia-Suicide Severity 

Rating Scale, are not currently available. This well-known instrument was first developed to 

assess suicidal ideation and behavior in clinical trials. However, it has undergone substantial 

dissemination domestically and abroad in both research and clinical settings.59,105 In an ongoing 

study, the Columbia-Suicide Severity Rating Scale as well as 3 other commonly-used assessment

measures are being tested in 900 military personnel to determine which scale or combination of 

scales most accurately predicts suicidal behaviors within 3 months.106 Further studies of the 

accuracy of these methods and their applications in clinical populations would contribute greatly 

to the field.

Five other ongoing studies of risk assessment for suicide in Veterans and military personnel that 

were identified in our searches address some evidence gaps (Table 10). In addition, future 

research should be directed towards more concerted replication and in-depth examination of the 

most promising instruments, rather than continuing to examine numerous different instruments in 

exploratory and nondefinitive studies. Also, more research on other methods of risk assessment 

is needed, including population-level approaches and objective methods.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Population-level Approaches to Suicide Risk Assessment

Perhaps the most promising approach to suicide risk assessment in the near future involves 

capitalizing on so-called big data to sort individuals into higher- and lower-risk groups. The 

traditional approach to using big data has come from secondary data analyses of large population 

surveys, limiting analyses to the survey items the original investigators thought to include.107

Newer approaches, in contrast, use current information from patients’ medical records and could 

allow the opportunity to assess a patient’s risk in real time.

Studies that used big data to analyze suicide deaths in the VA43 and the Army42 were included in 

this review. However, several other innovative studies were also identified that did not meet 

inclusion criteria. The first to be published was another study of VA patients that conducted 

exploratory data mining. Researchers employed a decision tree that allowed them to partition 

individuals whose VA health records were linked to the National Death Index for verification of 

death by suicide into high- and low-risk groups based on a constellation of indicators. Although 

this study took a novel approach, its results were similar to those found in prior studies using 

more traditional methods of risk factor identification.108

More recently, studies have explored machine-learning algorithms. Such approaches may 

analyze text from clinicians’ notes in the electronic medical record, as was done in one small 

study of Veterans.109 Similar machine-learning methods have been recently applied to multiple 

US Army and Department of Defense administrative data systems to identify high-risk strata to 

target suicide prevention interventions. In one study included in this review, administrative and 

medical data from over 50,000 psychiatric hospitalizations of soldiers were used to predict 

suicides in the subsequent year. Results showed that over half of 68 post-hospitalization suicides 

could be classified into a group of 5% of hospitalizations with the highest predicted suicide 

risk.42 Taxometric studies are a related, promising approach, in which researchers use multiple 

indicators to divide samples into high- and low-risk groups.110 Though these approaches are not 

yet ready for clinical applications, the relative ease of accessing and analyzing existing medical 

record data is promising.

Research conducted in large integrated community health systems may also be applicable to the 

VA. In one study, data from the Patient Health Questionnaire (PHQ-9) depression questionnaire

suggest that this may be a useful approach.

111 Ongoing work in this health system research 

network is extending applications of the PHQ-9, which is increasingly collected in routine 

clinical practice.

Future applications of results from Army STARRS, the largest study of mental health risk and 

resilience ever conducted among military personnel, could provide risk assessment methods 

uniquely applicable to the military. A series of important investigations from this project have 

been published recently published,

6,10 and more are expected in the near future. In addition, 

results of the Millennium Cohort Study, the largest longitudinal US military study, are also 

becoming available.112 This work provides important ongoing opportunities for risk assessment 

studies, particularly with the recent availability of public use datasets from the Army STARRS 

survey.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Objective Risk Assessment Methods

While most studies of risk assessment methods have relied on patient self-report data, an 

important exception is a study included in this review of the computer-administered Implicit 

Association Test, which uses individuals’ reaction times when classifying semantic stimuli in 

order to predict suicide attempts.

44 Although results of this study were not conclusive because of 

the small sample size and methodological limitations, it provided a novel approach that built on

previous developmental work, and may prove particularly useful in identifying individuals 

unwilling or unable to reveal their suicidal thoughts or intentions. Work evaluating similar 

methods in Veteran populations is currently ongoing,

113,114 including a study of the Affective 

Startle measure, which will use the eye blink reaction to different types of images to assess for 

suicide risk.115 Individuals with histories of suicide attempts exhibit certain patterns of cognitive 

deficits that can be detected by tasks commonly included in neuropsychological testing 

batteries.

116,117 However, future work is needed to determine whether this method could be useful 

in predicting suicidal behaviors. Another study evaluated attentional bias, or a tendency to pay 

more attention to suicide-related words presented to individuals in a modified version of a 

psychological test that measures reaction time (Stroop test). While results showed that the 

modified Stroop test may be useful in predicting suicide attempts, larger studies reporting 

diagnostic accuracy are needed.

118

Although studies have examined biological markers for suicide or other suicidal self-directed 

violence, this work is currently exploratory. A variety of candidate genes have been examined 

(TPH1, SLC6A2, and 5HTTLPR, among many others), but the interpretation and integration of 

results across studies is difficult and clinical applications are uncertain.

119-121 In general, studies 

use case-control designs and focus on gene-environment interactions in subjects with histories

significant for psychiatric disorders, adverse early life experiences, or both. For example, one 

study identified variants in a glutamatergic gene (GRIN2B) and polyaminergic gene (ODC1)

unique to individuals with histories of suicide attempt or early life physical assault.122 Nearly all 

currently published studies examined predominantly Caucasian populations and many required

invasive procedures, including several Swedish studies that required participants to undergo 

lumbar punctures to analyze their cerebrospinal fluid.

123-125 Other studies analyzed postmortem 

tissue samples of individuals who died by suicide.126,127 Fewer studies have used neuroimaging 

to identify associations with suicide-related outcomes.128,129 Research on biological markers and 

neuroimaging for assessing risk for suicide is expanding, but their role in clinical care has yet to 

be determined.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 10. Ongoing Studies of Methods to Identify Suicide Risk* 

Principal Investigator(s)/ 

Institution

Sponsors and 

Collaborators Study Title Population Purpose of Study

Anestis, M.114

University of Southern 

Mississippi

Military Suicide 

Research 

Consortium

Predicting Suicide 

Risk in a Military 

Population.

1,000 Veterans at an Army 

National Guard base.

Test a number of models for predicting suicidal behavior 

to see which are most effective for Veterans. Assessments 

will be taken at baseline, 6, 12, and 18 months, and will 

include standard measures of depression and hopelessness, 

as well as an Implicit Association Test to objectively 

detect unreported suicidal thoughts. The study will also 

examine whether additional information provided by a 

collateral reporter (ie, the person to whom the Veteran 

feels closest) can improve the accuracy of predicting future 

suicide attempts.

Bagge, C. & Conner, K.130

VISN 2 Center of 

Excellence for Suicide 

Prevention; University of 

Mississippi Medical 

Center; University of 

Rochester Medical Center

Military Suicide 

Research 

Consortium

Looking for Suicide 

Warning Signs.

500 Veterans and civilians 

with recent suicide 

attempts.

Identify warning signs that indicate when a suicide attempt 

is imminent. This will be accomplished by examining a 

comprehensive list of potential warning signs to see which 

can effectively distinguish when a suicide attempt is likely 

to occur in the next 6, 24, and 48 hours.

Hazlett, E. & Goodman, 

M.115

James J. Peters VA 

Medical Center

Department of 

Veterans Affairs 

(VISN 3 Mental 

Illness Research, 

Education & 

Clinical Center)

Affective Startle 

Assessment in High 

Risk Suicidal 

Veterans.

Veterans with suicide 

attempts, suicidal ideation, 

and with neither suicidal 

ideation nor attempt.

Determine whether Affective Startle, a validated, reliable, 

non-verbal psychophysiological measure of emotion 

processing, could be used as a biomarker to assess for 

suicide risk. The Affective Startle assessment consists of 

using electromyography to measure the eyeblink reaction 

to positive, neutral, and negative images and will be 

completed at baseline and 6-months follow-up.

Joiner, T. & Gutierrez, 

P.106

Florida State University; 

Denver VA Medical 

Center

Military Suicide 

Research 

Consortium

Toward a Gold 

Standard for Suicide 

Risk Assessment for 

Military Personnel.

900 military personnel 

seeking services from or 

referred to inpatient 

psychiatry, outpatient 

behavioral health services, 

or an emergency 

department because of 

concerns about suicide risk.

Identify a gold standard for clinical suicide risk assessment 

by testing 4 widely used measures against each other to 

determine which measure or combination of measures 

offers the most accurate prediction of suicide-related 

behaviors 3 months later. Measures include Columbia 

Suicide Severity Rating Scale, the Self-Harm Behavior 

Questionnaire, the Suicidal Behaviors QuestionnaireRevised, and the Beck Scale for Suicide Ideation. 

Najavits, L.

131

VA Boston Healthcare 

System

Department of 

Veterans Affairs 

(Health Services 

Assessment of Risk 

for Suicide, Violence 

and Related High74 Veterans with substance 

use disorder.

Determine whether the Short-Term Assessment of Risk 

and Treatability (START) can be implemented 

successfully in VA healthcare facilities and evaluate 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Principal Investigator(s)/ 

Institution

Sponsors and 

Collaborators Study Title Population Purpose of Study

Research & 

Development)

Risk Behaviors in 

Veterans.

whether START accurately predicts suicidality, 

aggression, and related high-risk behaviors among 

Veterans with substance use disorder.

Nock, M.113

Harvard University

Military Suicide 

Research 

Consortium

Looking for 

Cognitive Differences 

in Suicidal Veterans.

400 Veterans:

Part 1: psychiatric inpatient 

Veterans, 100 admitted for 

suicidal ideation or suicide 

attempt; 100 admitted for 

reasons unrelated to 

suicide. 

Part 2: depressed Veterans, 

100 with suicidal ideation 

plus 100 without suicidal 

ideation.

Determine cognitive differences between suicidal and nonsuicidal Veterans to develop new, objective ways of 

predicting suicide risk. The multiple-part study will test 

several facets of cognition, including time perception, 

attention to the present versus the past or future, and 

attention to suicide and psychological pain. Suicide 

attempts will be assessed 3 months after assessment.

*Ongoing studies were selected from websites and other sources identified by a search of grey literature based on their relevance to the key questions. The list of 

ongoing studies is likely incomplete because not all ongoing studies are included in these accessible sources.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Healthcare Service Interventions for Suicide Prevention 

Population-level Interventions

The 8 studies of population-level interventions for suicide prevention included in this review 

examined interventions comprised of multiple complex components implemented within existing 

organizational structures.74,78-81 For example, the Air Force Suicide Prevention Program included 

11 components grouped into 7 domains including engagement of military leaders, community 

education, continuous military training, and policy changes.74,78 While study results indicated 

reduced suicide rates after implementation of this program74,78 and 2 other initiatives in different 

settings,79,81 many essential questions have not yet been addressed. These include whether 

specific components of the intervention are more effective than others; whether characteristics of 

individuals nonresponsive to the intervention (ie, died from suicide) differ from those who were 

responsive; and how outcomes of the intervention differ from a concurrent, rather than historical, 

comparison group receiving usual standards of care. Future studies of the effectiveness of these 

interventions should be conducted in additional populations in order to further validate results of 

the initial studies, and, in some cases, to demonstrate the programs’ applicability to general 

clinical practice. Additional details about how the program components were actually 

implemented and maintained in practice are also necessary in order to establish portable service 

packages and translate this work to other settings. 

Restricting access to lethal means (or simply, means restriction) can be an effective method of 

suicide prevention,1,31 although no recently published studies of healthcare services using this 

approach met inclusion criteria for this review. Examples of current efforts in the VA to reduce 

access to lethal means include an ongoing study of blister packaging for medications132 and 

distribution of gun locks. Studies examining efforts to counsel Veterans on firearms safety and 

delaying or restricting access to firearms have been published,133,134 but more work is needed to 

help guide these clinician discussions with Veterans and to establish the effectiveness of such 

strategies for VA healthcare settings. 

Individual-level Interventions 

Studies of individual-level interventions included in this review generally targeted individuals 

identified as high-risk for suicide based on recent suicide attempts or self-harm72,76,77,92-94 or 

existence of psychiatric conditions.73,75,91,95 Few studies have evaluated the effectiveness of 

prevention interventions among individuals who do not have these characteristics. Additional 

research to develop health-promotion approaches that target known risk factors for suicide have 

been called for by experts in the field within the VA, Department of Defense, and the Centers for 

Disease Control and Prevention.135-137 Programs such as the European Alliance Against 

Depression138,139 and an ongoing study of cognitive behavioral therapy to reduce hopelessness 

called Window to Hope for Veterans with traumatic brain injury140 are examples of such work. 

These interventions address known risk factors for suicide (depression and traumatic brain 

injury, respectively) over the short term, with the goal of reducing suicide behaviors over the 

long term. Research is needed to determine the validity of this assumption.

Studies of interventions targeting protective factors for suicide are also needed.137,141-144

Protective factors, such as meaning in life, grit, gratitude, and social support, have been found to 

be negatively associated with suicidal ideation or attempts and may protect at-risk individuals 

from enacting suicidal behaviors.145-149 For example, interventions to increase social integration 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

54

may be especially effective in reducing suicide rates.147,148 As risk and protective factors become 

more clearly characterized through the ongoing work of the Army STARRS and other studies, 

innovative interventions that reduce suicide risk and bolster protective factors need to be 

evaluated in well-designed RCTs in order to effectively translate these research efforts to clinical 

practice. 

The 3 recently published trials91-93 and 5 earlier trials72,73,75-77 of individual-level interventions 

included in this review evaluated the effectiveness of psychotherapies or care management 

approaches for individuals with identified suicide risk. Of these, only 2 studies indicated fewer 

suicide attempts with therapy versus usual care,

75,93 and most others were underpowered to detect 

differences. Moreover, all trials met criteria for high or unclear risk of bias. Improvement of this 

evidence base will require larger, more rigorous RCTs of the effectiveness of existing 

interventions, such as the Collaborative Assessment and Management of Suicidality,150

dialectical behavior therapy,75,151 cognitive behavioral therapy and variants,152,153 and 

motivational interviewing for suicidal ideation.154

In addition to strengthening evidence for established interventions, research should also include 

evaluations of the effectiveness of innovative approaches. Using technology to support or 

enhance care for individuals at risk for suicide is an emerging area. For example, efforts are 

currently under way to evaluate caring emails and text messages as a method of follow-up and 

continued contact,155-158 crisis support through online chat forums for Veterans,159 crisis text 

messaging,160,161 and smartphone applications as accessories to therapy.162,163 More work 

evaluating outcomes of these efforts and developing additional resources is needed.

Despite implementation of safety planning in VA care settings, evidence to support its use has 

not yet been established. Safety plans help the patient document person-specific warning signs or 

triggers for suicidal thoughts as well as resources the patient can access when he or she is feeling 

suicidal. They are usually completed with the help of a clinician or other clinical staff and are 

intended to help the patient recognize when he or she may need extra help and to utilize the 

previously identified resources. Recently completed trials of safety planning in emergency 

department settings for both VA and military populations164-166 are beginning to report findings

on care utilization outcomes,

167 and another study is currently under way.168,169 However, the 

effectiveness of this intervention in reducing suicidal behaviors has not yet been determined.

Peer support specialists in the VA are Veterans with lived experience with mental illness who 

help provide social support and mental health assistance for Veterans receiving VA care. Peer 

support initiatives draw from evidence of the benefits of social support and the idea that others 

can benefit from the lived experience of those who have recovered from substance abuse or other 

mental health conditions. Efforts to evaluate this use of peer supporters in suicide prevention 

efforts have recently begun. For example, a recently completed study examined the feasibility of 

personal health planning and peer support among Veterans after psychiatric hospitalizations.170

Additionally, an ongoing pilot project is studying peer mentorship to reduce the risk of suicide 

after psychiatric hospitalizations.171 Continued work in this area should focus on establishing 

training requirements, functions, and eligibility of peer supporters, as well as evaluating efficacy 

and effectiveness in reducing suicidal behaviors.

Our searches identified 17 studies of individual-level healthcare service interventions for suicide 

prevention in Veteran and military populations that are currently in progress (Table 11). 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 11. Ongoing Studies of Healthcare Service Interventions for Suicide Prevention* 

Principal 

Investigator(s)/ 

Institution

Sponsors and 

Collaborators Study Title Population

Suicidal SelfDirected Violence 

Outcomes Purpose

Estimated 

Study 

Completion

Bryan, C.168,169

University of Utah, 

National Center for 

Veterans

Military Suicide 

Research Consortium 

(MSRC); University 

of Texas Health 

Science Center at San 

Antonio

Brief Intervention 

for Short-Term 

Suicide Risk 

Reduction in 

Military 

Populations. 

360 active-duty 

military personnel 

with current 

suicidal ideation 

with intent to die or 

recent suicide 

attempt. 

Suicide attempt at 6 

months (using the 

SASII). 

To determine the effectiveness of 3 

brief interventions for reducing shortterm risk for suicide attempts in “real 

world” military triage settings. 

Participants will be randomized to one

of 3 commonly-used crisis 

interventions delivered as routine care 

in the mental health triage system: 

treatment as usual, the Crisis Response 

Plan (CRP), or Enhanced Crisis 

Response Plan with Reasons for Living 

(E-CRP).

December 

2015

Bush, N. & Dobscha, 

S.163 

National Center for 

Telehealth and 

Technology; Portland 

VA Medical Center 

The Geneva 

Foundation; Portland 

VA Medical Center

Virtual Hope Box –

Effectiveness of a 

Smartphone App for 

Coping With 

Suicidal Ideation 

(VHB-RCT).

120 Veterans in 

active treatment 

who are at high risk 

for suicide.

Suicidal behavior at 

12 weeks (using CSSRS). 

Assess the impact of a virtual hope box 

(VHB) smartphone app on suicidal 

ideation in Veterans undergoing clinical 

therapy who have recently had suicidal 

ideation or behavior.

October 

2015

Comtois, K.155,157

University of 

Washington

University of 

Washington; Military 

Suicide Research 

Consortium (MSRC); 

Department of 

Veterans Affairs; 

Department of 

Defense

Military Continuity 

Project (MCP). 

800 active duty, 

Reserve, or 

National Guard 

members with a 

recent suicide 

attempt or suicidal 

ideation.

Suicidal behavior at 

12 months (using the 

SASI-C). 

Investigate the efficacy of a Continuing 

Contacts via Text intervention that 

extends the continuity of care for 

service members who have engaged in 

suicidal behavior and/or reported 

suicidal ideation by sending them 

regular caring text messages over a 12-

month period.

October 

2015

Goodman, M.172

University of 

Washington

Bronx Veterans 

Medical Research 

Foundation, Inc.

High Risk Suicidal 

Behavior in 

Veterans.

500 Veterans at 

high risk for 

suicide.

Suicidal events at 6 

months (using CSSRS). 

Examine the efficacy of Dialectical 

Behavior Therapy in reducing suicidal 

behavior in a diagnostically 

heterogeneous group of Veterans with 

high risk for suicidal behavior.

December 

2015

Goodman, M.173

Department of 

Veterans Affairs 

Department of 

Defense

High Risk Suicidal 

Veterans – 

Predictors of Suicide 

120 Veterans 

recently discharged 

from psychiatric 

Suicidal events at 18 

months (using CSSRS).

Compare outcomes for Veterans 

receiving treatment-as-usual with 

outcomes for Veterans who receive 6 

April 2014
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

56

Principal 

Investigator(s)/ 

Institution

Sponsors and 

Collaborators Study Title Population

Suicidal SelfDirected Violence 

Outcomes Purpose

Estimated 

Study 

Completion

(VISN 3 Mental 

Illness Research, 

Education & Clinical 

Center)

Risk and Efficacy of 

Dialectal Behavior 

Therapy. 

hospitalization for 

high-risk suicidal 

behavior. 

months of Dialectical Behavior 

Therapy, consisting of weekly 

individual sessions, skills training 

group and telephone coaching as 

needed.

Gutierrez, P.132

VA Eastern Colorado 

Health Care System

VA Eastern Colorado 

Health Care System; 

Department of 

Defense

Blister Packaging 

Medication to 

Increase Treatment 

Adherence and 

Clinical Response 

(BP).

303 psychiatric 

patients treated at 

the Denver VA 

Medical Center.

Suicide and suicide 

attempts at 12 

months. 

Determine if increased prescription 

medication adherence via blister pack 

administration will reduce suicide 

related behavior among the high risk 

population of patients discharged from 

a psychiatric inpatient unit.

September 

2014

Holloway, M.174

Uniformed Services 

University of the 

Health Sciences

Henry M. Jackson 

Foundation for the 

Advancement of 

Military Medicine; 

Department of 

Veterans Affairs

Post Admission 

Cognitive Therapy 

(PACT) for the 

Inpatient Treatment 

of Military 

Personnel with 

Suicidal Behaviors.

218 military 

service members 

and beneficiaries

hospitalized for 

severe suicide 

ideation or recent 

suicide attempt.

Repeat suicide 

attempt at 12 months 

(using the C-SSRS). 

Evaluate the efficacy of a cognitive 

behavioral intervention program, the 

Post Admission Cognitive Therapy 

(PACT), for military service members 

and beneficiaries admitted for inpatient 

care due to severe suicide ideation 

and/or recent suicide attempt.

February 

2019

Holloway, M.175

Uniformed Services 

University of the 

Health Sciences

Henry M. Jackson 

Foundation for the 

Advancement of 

Military Medicine; 

National Alliance for 

Research on 

Schizophrenia and 

Depression

Inpatient Post 

Admission 

Cognitive Therapy 

(PACT) for the 

Prevention of 

Suicide Attempts. 

24 service 

members and 

beneficiaries at 

hospitalized for 

recent suicide 

attempts.

Repeat suicide 

attempt at 3 months 

(using the C-SSRS). 

Evaluate a new manual of PostAdmission Cognitive Therapy (PACT) 

as a targeted inpatient treatment for 

individuals admitted for a recent 

suicide attempt to a military hospital.

December 

2015

Holloway, M.176

Uniformed Services 

University of the 

Health Sciences

Henry M. Jackson 

Foundation for the 

Advancement of 

Military Medicine, 

Congressionally 

Directed Medical 

Research Programs

Pilot Trial of 

Inpatient Cognitive 

Therapy for the 

Prevention of 

Suicide in Military 

Personnel 

(CDMRP). 

50 service 

members and 

beneficiaries with 

symptoms of acute 

stress disorder or 

posttraumatic stress 

disorder 

hospitalized for a 

recent suicide 

attempt.

Repeat suicide 

attempt at 3 months 

(using the C-SSRS). 

Evaluate an inpatient-based cognitive 

behavioral care plan, the PostAdmission Cognitive Therapy (PACT),

for service members and beneficiaries 

with symptoms of either Acute Stress 

Disorder or Posttraumatic Stress 

Disorder, who are admitted for 

hospitalization following a recent 

suicide attempt.

December 

2015
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Principal 

Investigator(s)/ 

Institution

Sponsors and 

Collaborators Study Title Population

Suicidal SelfDirected Violence 

Outcomes Purpose

Estimated 

Study 

Completion

Ilgen, M.177

VA Ann Arbor 

Healthcare System

Department of 

Veterans Affairs 

Crisis Line 

Facilitation (CLF).

500 Veterans under 

treatment for a 

suicidal crisis in a 

Veterans Health 

Administration 

inpatient 

psychiatric unit.

Suicide attempt at 

12 months (using CSSRS). 

Test a new single-session intervention, 

Crisis Line Facilitation (CLF), which 

addresses Veterans’ perceived barriers 

and facilitators of crisis line use during 

periods of suicidal crisis. The 

intervention will be compared to an 

enhanced usual care condition, with 

outcomes including suicide attempt and

utilization of the Veterans Crisis Line.

April 2018

Ilgen, M.178

University of 

Michigan

University of 

Michigan; US Army 

Medical Research 

and Materiel 

Command; 

Department of 

Defense; Department 

of Veterans Affairs

Intervening to 

Reduce Suicide Risk 

in Veterans with 

Substance Use 

Disorders. 

300 Veterans with 

a Substance Use 

Disorder and

current suicidal 

ideation.

Suicide attempt at 

24 months (using the 

C-SSRS). 

Evaluate the impact of a Cognitive 

Behavioral Therapy intervention 

compared to a Supportive 

Psychoeducational Control in reducing 

the frequency and intensity of suicidal 

thoughts and behaviors in Veterans 

with substance use disorders over a 2-

year follow-up period.

November 

2018

Interian, A.179

Lyons Campus of the 

VA New Jersey 

Health Care System

Department of 

Veterans Affairs

Mindfulness-Based 

Cognitive Therapy 

for Suicide 

Prevention (MBCTS).

164 Veterans at 

high risk for 

suicide.

Suicidal behaviors at 

12 months (using 

VA’s Self-Directed 

Violence 

Classification 

System); Suicide 

attempt at 12 months 

(using C-SSRS).

Test a psychotherapeutic intervention, 

the Mindfulness-Based Cognitive 

Therapy, which integrates cognitive 

therapy and mindfulness meditation 

techniques to prevent suicide in 

military Veterans. 

September 

2017

Jobes, D.180

The Catholic 

University of 

America

The Catholic 

University of 

America; University 

of Washington; 

Department of 

Veterans Affairs

Operation Worth 

Living Project With 

Suicidal Soldiers at 

Ft. Stewart (OWL).

150 Active duty 

Army personnel at 

Ft. Stewart with 

significant suicidal 

ideation.

Suicide attempts. Compare the use of new clinical 

intervention, the Collaborative 

Assessment and Management of 

Suicidality (CAMS), versus enhanced 

care as usual for suicidal soldiers who 

are seen at outpatient mental health 

clinics at Ft. Stewart, Georgia.

December 

2015

Luxton, D.156,158

National Center for 

Telehealth and 

Technology

National Center for 

Telehealth and 

Technology, 

Department of 

Caring Letters for 

Military Suicide 

Prevention.

4,730 active duty 

military members 

or Veterans who 

are current 

Suicide at 2 years 

(using death 

certificates in the 

National Death 

Determine if the Caring Letters 

intervention is effective in preventing 

suicide and suicidal behaviors among 

US Service Members and Veterans.

February 

2017
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

58

Principal 

Investigator(s)/ 

Institution

Sponsors and 

Collaborators Study Title Population

Suicidal SelfDirected Violence 

Outcomes Purpose

Estimated 

Study 

Completion

Defense, US Army 

Medical Research 

and Materiel 

Command

psychiatric 

inpatients.

Index Plus); suicidal 

behaviors requiring 

hospital admission 

(using electronic 

medical records).

Matarazzo, B.181

Rocky Mountain 

Mental Illness 

Research, Education, 

and Clinical Center 

(MIRECC)

Military Suicide 

Research Consortium 

(MSRC)

Improving the 

Inpatient-toOutpatient 

Transition.

700 Veterans from 

4 VA medical 

centers. 

Not reported. To test the Home-Based Mental Health 

Evaluation program (HOME), designed 

to lower risk of suicide after discharge 

from an inpatient psychiatric unit by 

creating a better transition between 

inpatient and outpatient care for 

Veterans who are at risk of suicide. 

Not reported.

Primack, J. M.182

Providence VA 

Medical Center

Department of 

Veterans Affairs; 

Butler Hospital

Veterans Coping 

Long-term With 

Active Suicide 

(CLASP-VA).

300 Veterans at 

high risk for 

suicide discharged 

from a VA hospital 

.

Suicidal attempts at 

12 months (using CSSRS). 

Test the efficacy of the Veterans 

Coping Long Term with Active Suicide 

Program (CLASP-VA) intervention to 

reduce suicide behaviors in Veterans. 

CLASP-VA is a telephone-based 

intervention that combines elements of 

individual therapy, case management, 

and significant other/family therapy, 

and directly targets high-risk patients at 

the time of hospital discharge.

September 

2017

VA Eastern Colorado 

Health Care 

System165,183

VA Eastern Colorado 

Health Care System; 

Department of 

Veterans Affairs; 

Department of 

Defense

A Brief Intervention 

to Reduce Suicide 

Risk in Military 

Service Members 

and Veterans- Study 

1 (SAFE VET).

600 Veterans at VA 

emergency 

departments. 

Suicide attempt at 6 

months (using CSSRS).

Evaluate the Suicide Assessment and 

Follow-up Engagement: Veteran 

Emergency Treatment (SAFE VET) 

intervention, designed to attenuate 

suicide risk by helping Veterans 

manage suicidal thoughts and 

behaviors, and adhere to prescribed 

clinical care.

March 2015

*Ongoing studies were selected from websites and other sources identified by a search of grey literature based on their relevance to the key questions. The list of 

ongoing studies is likely incomplete because not all ongoing studies are included in these accessible sources.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

59

SUMMARY AND DISCUSSION

A summary of evidence is provided in Table 12 and strength of evidence ratings for studies of 

healthcare service interventions for suicide prevention are provided in Table 13.

SUMMARY OF EVIDENCE BY KEY QUESTION

Key Question 1

A. What are the accuracy and adverse effects of methods to identify Veterans 

and military personnel at increased risk for suicide and other suicidal selfdirected violence? 

B. Does accuracy and adverse effects vary by settings, delivery modes, targeted 

populations, or other factors? 

Fifteen recently published studies and 4 from the previous VA ESP systematic review evaluated 

the accuracy of methods to identify individuals at risk for suicide and other suicidal self-directed 

violence and met inclusion criteria for this review. These include 2 case-control studies and 17

case-series studies designed to determine measures of diagnostic accuracy. No studies evaluated 

the adverse effects of risk assessment methods, or compared how accuracy and adverse effects 

vary by settings, delivery modes, targeted populations, or other factors.

Results of studies indicated estimates of sensitivity ranging from 11% to 100% and AUC from 

0.57 to 0.97. Several risk assessment methods had estimates of sensitivity ≥80% or AUC ≥0.70,

suggesting fair or better discrimination between patients with and without suicides or suicide 

attempts. Several studies used data from electronic medical records or administrative databases 

to identify individuals with known risk factors for suicide. The most relevant study used data 

from nearly 6 million patients of the VA to create a prediction model to stratify patients 

according to their risk for suicide within the next year. This method had an AUC of 0.761 (95% 

CI, 0.751 to 0.771).

Four additional studies of Veterans were included in the previous VA ESP review. In one study, 

a decision tree for identifying high-risk patients was derived from the Addiction Severity Index 

and variables from VA databases. Sensitivity/specificity varied across the 3 prediction models 

that were evaluated (33%/87%, 72%/63%, 89%/42%). Three studies of Veterans evaluated the 

accuracy of established instruments to predict suicidal attempts and suicide. Results indicated 

high sensitivity/specificity for the Suicide Potential Index (91%/77%), and lower estimates for 

the Beck Depression Inventory (63%/80%) and Affective States Questionnaire (60%/74%).

The only study of military personnel was based on Army STARRS and included 40,820 active 

duty US Army soldiers hospitalized with psychiatric admission diagnoses. A risk algorithm to 

predict suicides within one year of hospitalization was developed from administrative data 

systems and demonstrated AUCs as high as 0.89.

Additional studies of non-Veterans evaluated the diagnostic accuracy of the risk instruments, 

including the Affective Intensity Rating Scale, Barwon Health Suicide Risk Assessment, 

Death/suicide Implicit Association Test, SAD PERSONS, Schedule for Nonadaptive and 

Adaptive Personality, Suicide Opinion Questionnaire, Sleep Quality Index, Suicidal Ideation 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Attributes Scale, and Suicide Trigger Scale. Results indicated a wide range of estimates 

depending on the instrument and selected cut-points.

Current conventions do not provide strength of evidence grades for diagnostic accuracy studies. 

Studies of methods of risk assessment that were derived from large databases provided a rigorous 

approach with low risk of bias and high clinical applicability. Results indicated fair or better 

diagnostic accuracy for some of the models. These methods should be replicated in additional 

patient populations to refine the data variables and optimal cut-points, and further validate 

findings before they are adapted to clinical care uses.

Studies based on the diagnostic accuracy of individual instruments and scales are also useful, but 

are currently limited by small sample sizes, methodological limitations, and unclear applicability.

Risk assessment instruments may provide diagnostic value to specific patient subgroups, such as 

those with previous suicide attempts or co-existing conditions. However, the current evidence 

base includes numerous inconclusive, small studies of a variety of instruments. Instruments 

demonstrating fair to good diagnostic accuracy in these studies should be further tested in larger 

clinical populations.

Key Question 2

What are the efficacy/effectiveness and adverse effects of suicide prevention 

interventions in reducing rates of suicide and other suicidal self-directed violence 

in Veterans and military personnel? Interventions include healthcare services 

directed towards A) populations and B) individuals.

Population-level Healthcare Interventions 

Eight studies of the efficacy or effectiveness of population-level healthcare interventions met 

inclusion criteria, including a follow-up analysis of a study that was included in the previous VA 

ESP review. These studies evaluated multi-component initiatives implemented within existing 

organizational structures that included military populations, police officers, college students, and 

healthcare systems. One study was designed as a retrospective cohort study, 5 were before-after 

studies, one was an ecological comparison study, and one was a post intervention series. All 

interventions except for one were designed for primary prevention of suicide. No studies 

evaluated adverse effects of population-level interventions.

Three studies evaluated interventions in military personnel or police officers. An initial beforeafter study of the Air Force Suicide Prevention Program, an Air Force-wide intervention that 

included policy and education initiatives, found that implementation of the program was 

associated with reduced risk for suicide in over 5 million active duty US Air Force personnel.

Long-term follow-up also indicated reduced suicide rates after implementation. A program in an 

Army Infantry Division deployed to Iraq also resulted in lower suicide rates for the intervention 

unit compared with rates for service members in theater and for the US Army specifically, 

although statistical comparisons were not provided. Suicide rates were statistically significantly 

lower after implementation of a suicide prevention program among police officers in Montreal.

Additional studies evaluated population-level interventions implemented in healthcare and other 

settings. Suicide rates were reduced in studies of the Perfect Depression Care initiative in a large 

health maintenance organization in the US; implementation of service recommendations in 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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England and Wales; and after a mandated secondary prevention program for college students in a 

US university. No reductions were found in a study of the long-term impact of specialized early 

psychosis treatment on suicidal behaviors in Australia, and among adults in a community 

program in the US.

The strength of evidence grades for population-level healthcare interventions are insufficient for 

suicide attempt outcomes (no studies), low for suicide outcomes (8 observational studies), and 

insufficient for adverse effects (no studies). The low strength of evidence grade for suicide 

outcomes indicates that additional evidence is needed before concluding either that the findings 

are stable or that the estimate of effect is close to the true effect. Although 6 of the 8 studies of 

interventions suggested reductions in suicide rates, the interventions varied across studies, risk of 

bias was unclear, and the comparability of comparison groups was not established. While the 

studies provided promising initial findings, these interventions should be replicated under more 

controlled conditions, such as in RCTs, to strengthen the evidence of their effectiveness.

Individual-level Healthcare Interventions 

Five recently published RCTs and 5 trials from the previous VA ESP review met inclusion 

criteria. No studies evaluated adverse effects of interventions. Trials compared usual care to 

individual psychotherapies, including cognitive behavioral therapy, dialectical behavior therapy, 

personal construct psychotherapy, problem-solving therapy or skills training, and day hospital 

treatment. Trials enrolled outpatient military personnel and non-military psychiatric inpatients or 

patients at acute risk for suicide. No studies enrolled Veterans specifically and no studies 

evaluated the adverse effects of individual-level interventions.

Only 2 trials reported statistically significant differences between treatment and usual care. In 

one trial, outpatient active duty soldiers with recent suicide attempts or ideation in a brief 

cognitive behavioral therapy program were less likely to make suicide attempts at 2 years followup than those in usual care. In a trial of women with borderline personality disorder, those

receiving dialectical behavior therapy had fewer suicide attempts compared with those receiving 

usual care at one year follow-up.

The strength of evidence grades for individual-level healthcare interventions are low for suicide 

attempt outcomes (7 trials), insufficient for suicide outcomes (4 trials), and insufficient for 

adverse effects (no studies). The low strength of evidence grade for suicide attempt outcomes 

indicates that additional evidence is needed before concluding either that the findings are stable 

or that the estimate of effect is close to the true effect. The most relevant trial, comparing brief 

outpatient cognitive behavioral therapy versus usual care in Army soldiers, indicated statistically 

significantly reduced suicide attempts for the intervention group, although its risk of bias was 

unclear. These findings support cognitive behavioral therapy as a suicide prevention intervention 

and are consistent with other trials of cognitive behavioral therapy in various population groups 

and settings that did not meet inclusion criteria for this review.15,16 Larger trials of similar 

therapies in Veteran and military populations would build on this work and strengthen the 

evidence base.

The insufficient strength of evidence grade for suicide outcomes indicates that the body of 

evidence has unacceptable deficiencies that preclude deriving conclusions. In this case, the 4 

trials reporting suicide outcomes had too few participants and suicide events to determine 

statistically significant differences between treatment and usual care. These interventions require 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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replication in larger trials that are sufficiently powered to detect differences in order to determine 

their effectiveness in suicide prevention.

LIMITATIONS

Study Quality

For studies of risk assessment, risk of bias was rated low in 3 studies, high in 6, and unclear in 

10. Limitations of studies with high or unclear risk of bias included biased or unclear selection 

criteria for the study populations; non-standardized risk assessment procedures; inadequate 

outcome assessments; small sample sizes; and high or unclear loss to follow-up.

Risk of bias for studies of population-level interventions was unclear for the retrospective cohort 

study, and could not be determined for other studies because of the lack of risk of bias criteria for 

these study designs. Limitations of studies included inadequate consideration of potential 

confounders, non-comparability of comparison groups, and lack of information on usual care.

Risk of bias for trials of individual-level interventions was rated high in 5 trials and unclear in 5.

Most studies were underpowered to detect differences between treatment and usual care.

Limitations of studies included lack of information on randomization, allocation concealment, 

blinding, and outcome reporting; and unclear or lack of specified outcome measures.

Heterogeneity

Studies were highly heterogeneous for both the risk assessment and prevention intervention key 

questions included in this review. Specific risk assessment methods and prevention interventions 

were rarely examined in more than one study, precluding statistical meta-analysis of results and 

limiting applicability to clinical practice. In addition, studies were generally conducted in small, 

specialized populations that may yield unique results. Future research to reduce heterogeneity 

will improve the evidence base, such as a recent effort by the National Institutes of Health, VA,

and Department of Defense to define common data elements for suicide prevention research.184

Applicability of Findings to the VA Population

Of the 37 studies included in this review (including 9 from previous VA ESP reviews), 5 studies

of risk assessment included Veterans and one included active military personnel, and 3 studies of 

interventions included active military personnel. In addition, inclusion criteria for studies 

enrolling participants outside Veterans and military populations focused on participants with 

similar demographic characteristics. While these criteria may have excluded important studies, 

they also improved the systematic review’s clinical relevance to the VA population.

CONCLUSIONS

Studies of risk assessment methods to identify individuals at increased risk for suicide and other 

suicidal self-directed violence evaluated numerous different approaches. Methods derived from 

data from electronic medical records, including studies of Veterans and military personnel, were 

robust predictors of subsequent suicide. Studies of various clinician-rated or patient self-report

risk assessment instruments indicated accuracy that varied across methods and cut-points.

Studies of multi-component population-level suicide prevention interventions and individual 

cognitive behavioral therapy in military populations showed reduced suicide attempts and 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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suicide. However, evidence is limited by the many single, inconclusive studies of various risk 

assessment instruments and prevention interventions, methodological deficiencies of studies, 

inherent challenges in conducting research in this area, and lack of studies addressing adverse 

effects.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Table 12. Summary of Evidence

Key Question Number/Type of Studies Risk of Bias and Limitations Summary of Findings

1A What are the accuracy 

and adverse effects of 

methods tof identify 

Veterans and military 

personnel at increased 

risk for suicide and other 

suicidal self-directed 

violence? 

15 new studies and 4 

from the previous ESP 

review.

2 case-control studies, 

17 case-series; all were 

designed to determine 

diagnostic accuracy.

5 studies of Veterans; 1 

of active military.

Risk of bias: 3 studies low; 6 high; 10

unclear.

Limitations: biased or unclear selection 

criteria for the study populations; nonstandardized risk assessment procedures; 

inadequate outcome assessments; small

sample sizes; high or unclear loss to followup; potentially biased participant selection.

No studies of adverse effects.

Studies used models derived from databases or clinicianrated or patient self-report instruments. 

Accuracy varied across methods and cut-points; sensitivity 

ranged from 11% to 100%; AUC from 0.57 to 0.97. 

Method to predict suicide derived from database of >5

million VA patients: AUC 0.761 (95% CI, 0.751 to 0.771).

Method to predict suicide derived from database of US 

active military with psychiatric hospitalizations: AUC 

0.89.

1B Does accuracy and 

adverse effects vary by 

settings, delivery modes, 

targeted populations, or 

other factors? 

No studies Not applicable Not applicable

2 What are the efficacy/effectiveness and adverse effects of suicide prevention interventions in reducing rates of suicide and other suicidal self-directed violence in 

Veterans and military personnel?

2A Healthcare services 

directed towards 

populations.

6 before-after studies; 1 

post intervention series; 

1 retrospective cohort 

study.

2 studies in active US 

military; 1 study in 

Canadian police.

Risk of bias: unclear for the retrospective 

cohort study; could not be determined for 

other studies.

Limitations: inherent biases of ecological 

studies; confounders not considered; noncomparability of comparison groups; no 

information on usual care.

No studies of adverse effects.

Suicide rates were lower after interventions in 6 studies, 

including studies of the Air Force Suicide Prevention 

Program; a program for an Army Infantry Division 

deployed to Iraq; and studies of police, college students, 

and health systems.

Suicide rates were not lower in 2 studies of community 

programs. 

2B Healthcare services 

directed towards 

individuals.

5 new RCTs; 5 RCTs 

from the previous ESP 

review.

1 RCT in active 

military. 

Risk of bias: high in 5 studies; unclear in 5.

Most studies were underpowered to detect 

differences between comparisons.

Limitations: lack of information on 

randomization, allocation concealment, 

blinding, and outcome reporting; unclear or 

lack of outcome measures.

No studies of adverse effects.

Active-duty soldiers with recent suicide attempts/ideation 

had fewer attempts 2-years after a brief cognitive 

behavioral therapy program versus usual care (13.8% vs

40.2%, P=.02; hazard ratio 0.38, 95% CI, 0.16 to 0.87). 

Women with borderline personality disorder had fewer 

suicide attempts one year following dialectical behavior 

therapy versus usual care (23% vs 46%; P=.01). 

8 other RCTs indicated no differences between treatment 

and usual care.

Abbreviations: AUC = area under the receiver-operator characteristic (ROC) curve; CI = confidence interval; ESP = Evidence-based Synthesis Program; RCT = 

randomized controlled trial. 
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Table 13. Strength of Evidence Ratings for Studies of the Efficacy/Effectiveness and Adverse Effects of Healthcare Service 

Interventions for Suicide Prevention

Outcome

Study Design/

Number of 

Studies (N)

Study 

Limitations Directness Consistency Precision

Reporting 

Bias Overall Effect

Strength of 

Evidence/ 

Grade*

Population-level interventions versus none 

Suicide attempt No studies Insufficient

Suicide 8 observational 

(N>5,000,000)

High Indirect Unknown Imprecise Unknown Decrease or 

none

Low

Adverse effects No studies Insufficient

Individual-level interventions (psychotherapy) versus usual care 

Suicide attempt 7 RCTs 

(N=670)

High Direct Unknown Imprecise Unknown Decrease or 

none

Low

Suicide 4 RCTs 

(N=1,337)

High Direct Unknown Imprecise Unknown Unclear Insufficient

Adverse effects No studies Insufficient

Abbreviations: RCTs = randomized controlled trials.

*Strength of Evidence tool from the Agency for Healthcare Research and Quality’s (AHRQ) Evidence-based Practice Centers (EPC).29 Rating Definitions: Low = 

Limited confidence that the estimate of effect lies close to the true effect for this outcome. The body of evidence has major or numerous deficiencies (or both). 

Additional evidence is needed before concluding either that the findings are stable or that the estimate of effect is close to the true effect.

Insufficient = No evidence, unable to estimate an effect, or no confidence in the estimate of effect for this outcome. No evidence is available or the body of evidence 

has unacceptable deficiencies, precluding reaching a conclusion.
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Reduce Suicide Risk Following Psychiatric Hospitalization (PREVAIL Study). 

ClinicalTrials.gov. 2015; NCT02365116. https://ClinicalTrials.gov/show/NCT02365116. 

Accessed September 28, 2015.

172. Bronx Veterans Medical Research Foundation. High Risk Suicidal Behavior in Veterans. 

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02462694. Accessed 

September 28, 2015.

173. Goodman M. High Risk Suicidal Veterans - Predictors of Suicide Risk and Efficacy of 

Dialectal Behavior Therapy. VISN 3 Mental Illness Research, Education & Clinical 

Center. http://www.mirecc.va.gov/visn3/clinical.asp#Behavior. Accessed September 30, 

2015.

174. Henry M. Jackson Foundation for the Advancement of Military Medicine, Department of 

Veterans Affairs, Duke University, et al. Post Admission Cognitive Therapy (PACT) for 

the Inpatient Treatment of Military Personnel With Suicidal Behaviors. 

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01359761. Accessed 

September 28, 2015.

175. Henry M. Jackson Foundation for the Advancement of Military Medicine, National 

Alliance for Research on Schizophrenia and Depression. Inpatient Post Admission 

Cognitive Therapy (PACT) for the Prevention of Suicide Attempts. ClinicalTrials.gov. 

2015; https://ClinicalTrials.gov/show/NCT01340859. Accessed September 28, 2015.

176. Henry M. Jackson Foundation for the Advancement of Military Medicine, 

Congressionally Directed Medical Research Programs. Pilot Trial of Inpatient Cognitive 

Therapy for the Prevention of Suicide in Military Personnel. ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT01356186. Accessed September 28, 2015.

177. Department of Veterans Affairs. Crisis Line Facilitation. ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT02459587. Accessed September 28, 2015.

178. University of Michigan, U. S. Army Medical Research and Materiel Command, 

Department of Defense, Department of Veterans Affairs. Intervening to Reduce Suicide 

Risk in Veterans With Substance Use Disorders. ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT02439762. Accessed September 28, 2015.

179. Department of Veterans Affairs, Columbia University Department of Psychology College 

of Physicians & Surgeons, Rutgers University Bloustein Center for Survey Research. 

Mindfulness-Based Cognitive Therapy for Suicide Prevention. ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT01872338. Accessed September 28, 2015.

180. The Catholic University of America, University of Washington, Department of Veterans 

Affairs. Operation Worth Living Project With Suicidal Soldiers at Ft. Stewart (OWL). 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

79

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01300169. Accessed 

September 25, 2015.

181. Matarazzo B. Improving the Inpatient-to-Outpatient Transition. Military Suicide 

Research Consortium. https://msrc.fsu.edu/funded-research/improving-inpatientoutpatient-transition. Accessed September 28, 2015.

182. Department of Veterans Affairs, Butler Hospital. Veterans Coping Long-term With 

Active Suicide (CLASP-VA). ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT01894841. Accessed September 28, 2015.

183. VA Eastern Colorado Health Care System, Department of Veterans Affairs, Department 

of Defense, Columbia University, University of Pennsylvania, Uniformed Services 

University of the Health Sciences. A Brief Intervention to Reduce Suicide Risk in 

Military Service Members and Veterans- Study 1. ClinicalTrials.gov. 2014; 

https://ClinicalTrials.gov/show/NCT01334541. Accessed September 28, 2015.

184. Office of Research & Development. Request for VA Research Community to Provide 

Input: Suicide Prevention Common Data Elements. US Department of Veterans Affairs. 

http://www.research.va.gov/resources/suicide_prevention.cfm. Accessed October 21, 

2015.
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APPENDIX A. SEARCH STRATEGIES

ELECTRONIC DATABASE SEARCHES 

Databases Searched

· MEDLINE via PubMed

· PsycINFO via OVID

· Cochrane Central Register of Controlled Trials (CCRCT) via OVID 

· SocINDEX* via EBSCOHost

Search Strategies 

All searches were updated September 11, 2015.

MEDLINE via PubMed

Searched March 3, 2015* 

Concept Search Terms

Suicide (("Suicide"[Mesh]) OR "Suicidal Ideation"[Mesh]) OR "Suicide, Attempted"[Mesh]

OR

(suicide[Title/Abstract] OR suicidal[Title/Abstract] OR suicidality[Title/Abstract] OR 

parasuicide[Title/Abstract] OR self-harm[Title/Abstract] OR "self-directed 

violence"[Title/Abstract] OR parasuicidal[Title/Abstract])

NOT "non-suicidal self injury"[Title/Abstract]

Prevention "prevention and control" [Subheading] OR "Tertiary Prevention"[Mesh] OR "Secondary 

Prevention"[Mesh] OR "Primary Prevention"[Mesh]

OR (prevent*[Title/Abstract] OR control[Title/Abstract])

Risk 

Prediction

((((("Risk"[Mesh]) OR "Risk Reduction Behavior"[Mesh]) OR "Risk Assessment"[Mesh]) 

OR "Risk Factors"[Mesh]) OR "Mass Screening"[Mesh]) OR "Validation Studies" 

[Publication Type]

OR

(risk[Title] OR screening[Title] OR screen[Title] OR assessment[Title] OR 

assessments[Title] OR questionnaire[Title] OR questionnaires[Title] OR instrument[Title] 

OR instruments[Title] OR tool[Title] OR tools[Title] OR scale[Title] OR scales[Title] OR 

measure[Title] OR measures[Title] OR correlate*[Title] OR “risk-stratification”[Title] OR 

predict[Title] OR predicts[Title] OR predictor[Title] OR predictors[Title])

OR 

(((((((ReACT Self Harm Rule[Title/Abstract]) OR Suicidal Ideation Attributes 

Scale[Title/Abstract]) OR Suicide Trigger Scale[Title/Abstract]) OR Cultural Assessment 

of Risk for suicide[Title/Abstract]) OR Affective Intensity Rating Scale[Title/Abstract]) 

OR Columbia Suicide Severity Rating Scale[Title/Abstract]) OR Edinburgh Risk of 

Repetition Scale[Title/Abstract]) OR Manchester Self Harm tool[Title/Abstract]

Limits:

Humans 

Adults 

English only 

Last 5 years

Not letters, 

editorials

NOT ((("Letter" [Publication Type]) OR "Editorial" [Publication Type]) OR "Comment" 

[Publication Type]) Filters: published from January 2008 to Present; Humans; English; 

Adult: 19+ years 

N=3411 

After de-duplication N=2913

*Update search on September 11, 2015; 4 additional records retrieved.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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PsychINFO via OVID 

Searched March 3, 2015* 

Database: PsycINFO <1806 to February Week 4 2015> 

Search Strategy:

-------------------------------------------------------------------------------- 

1 suicide/ or attempted suicide/ or suicidal ideation/ (29009)

2 (suicide or suicidal or suicidality or parasuicide or self-harm or "self-directed violence" or 

parasuicidal).mp. (49986) 

3 1 or 2 (49986) 

4 exp Suicide Prevention/ or prevention.mp. or exp Suicide Prevention Centers/ (98208) 

5 exp Risk Assessment/ or risk.mp. or exp Risk Factors/ (249298) 

6 (risk or screening or screen or assessment or assessments or questionnaire or questionnaires or 

instrument or instruments or tool or tools or scale or scales or measure or measures or correlate* or "risk 

stratification" or predict or predicts or predictor or predictors).mp. (1380001) 

7 ReACT Self Harm Rule.mp. (3) 

8 Suicidal Ideation Attributes Scale.mp. (2) 

9 Suicide Trigger Scale.mp. (4)

10 Cultural Assessment of Risk for suicide.mp. (5) 

11 Affective Intensity Rating Scale.mp. (2) 

12 Columbia Suicide Severity Rating Scale.mp. (183) 

13 Edinburgh Risk of Repetition Scale.mp. (2) 

14 Manchester Self Harm tool.mp. (0) 

15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 (1380001) 

16 4 or 15 (1420668) 

17 3 and 16 (30393) 

18 limit 17 to (peer reviewed journal and human and english language and treatment & prevention and 

adulthood <18+ years> and from January 2008 to Present) (1445) after deduplication N= 946

*Update search on September 11, 2015; 244 additional records retrieved. 

Cochrane Central Register of Controlled Trials (CCRCT) via OVID

Searched March 3, 2015* 

Database: EBM Reviews - Cochrane Central Register of Controlled Trials <January 2015> 

Search Strategy:

--------------------------------------------------------------------------------

1 suicide/ or attempted suicide/ or suicidal ideation/ (488) 

2 (suicide or suicidal or suicidality or parasuicide or self-harm or "self-directed violence" or 

parasuicidal).mp. (1720) 

3 1 or 2 (1720) 

4 exp Suicide Prevention/ or prevention.mp. or exp Suicide Prevention Centers/ (41007) 

5 exp Risk Assessment/ or risk.mp. or exp Risk Factors/ (83788) 

6 (risk or screening or screen or assessment or assessments or questionnaire or questionnaires or 

instrument or instruments or tool or tools or scale or scales or measure or measures or correlate* or "risk 

stratification" or predict or predicts or predictor or predictors).mp. (272313) 

7 ReACT Self Harm Rule.mp. (0) 

8 Suicidal Ideation Attributes Scale.mp. (0) 

9 Suicide Trigger Scale.mp. (0)

10 Cultural Assessment of Risk for suicide.mp. (0) 

11 Affective Intensity Rating Scale.mp. (0) 

12 Columbia Suicide Severity Rating Scale.mp. (11) 

13 Edinburgh Risk of Repetition Scale.mp. (0) 
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14 Manchester Self Harm tool.mp. (0) 

15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 (272313) 

16 4 or 15 (293030) 

17 3 and 16 (1319) 

18 limit 17 to (peer reviewed journal and human and english language and treatment & prevention and 

adulthood <18+ years> and from January 2008 to Present) [Limit not valid; records were retained] (583) 

after deduplication 342

*Update search on September 11, 2015; 202 additional records retrieved.

SocINDEX* via EBSCOHost 

Searched March 6, 2015 

Search Strategy:

--------------------------------------------------------------------------------

S1 TI suicide OR suicidal OR suicidality OR parasuicide OR self-harm OR "self directed violence" 

OR parasuicidal 

S2 DE "HEALTH risk assessment" OR DE "SUICIDAL behavior -- Risk factors" 

S3 DE "SUICIDE" OR DE "SUICIDAL behavior” 

S4 DE "SUICIDE prevention" OR DE "PREVENTIVE medicine" 

S5 TI prevent* OR control OR risk OR screen OR screen OR assessment OR assessments OR 

questionnaire OR questionnaires OR instrument OR instruments OR tool OR tools OR scale OR scales 

OR measure OR measures OR correlate* OR "risk-stratification" OR predict OR predicts OR predictor 

OR predictors 

S6 S1 OR S3

S7 S2 OR S4 OR S5 

S8 S6 AND S7

S9 S6 AND S7 Limiters - Date of Publication: 20100101-20151231 

N= (317) 223 after deduplication 

*Update search on September 11, 2015; 0 additional records retrieved.

GREY LITERATURE SEARCHES

Search Strategies

All grey literature searches were completed on July 16, 2015. 

Conferences and Organizations:

American Association of 

Suicidology 

http://www.suicidology.org/

DOD VA Suicide 

Prevention Conference 

http://www.suicideoutreach.org

International Suicide 

Summit

http://www.suicide-research.org/

American Foundation of 

Suicide Prevention

https://www.afsp.org/

Military Suicide Research 

Consortium

https://msrc.fsu.edu/

The Mental Illness 

Research, Education and 

http://www.mirecc.va.gov/
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Clinical Centers (MIRECC)

Suicide Prevention Resource 

Center

http://www.sprc.org 

Other Sources:

ClinicalTrials.gov http://clinicaltrials.gov

NIH RePORTER http://projectreporter.nih.gov/reporter.cfm

Journals Searched Individually: 

Depression and Anxiety http://onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291520-6394

JAMA Psychiatry http://archpsyc.jamanetwork.com/Solr/advancedSearch.aspx

Injury Prevention http://injuryprevention.bmj.com/search

Suicide and Life-threatening 

Behavior

http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291943-278X

Journal of Affective 

Disorders

http://www.jad-journal.com/search/advanced?seriesIssn=0165-

0327&searchType=advanced&journalCode=jad

Psychiatry : Interpersonal 

and Biological Processes

http://www.tandfonline.com/loi/upsy20#.VTEnqpPVr0w
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APPENDIX B. STUDY SELECTION 

Inclusion Criteria

Category Include Exclude

Population Veterans; military personnel; non-Veteran/military 

individuals age ≥18 who are demographically similar from 

US, UK, Canada, New Zealand, or Australia.

Individuals dissimilar to the included 

population; patients with other serious 

psychiatric or medical co-morbidities 

(eg, cancer).

Intervention Population-directed healthcare services (eg, hotlines, 

outreach programs); individual-directed healthcare services 

(eg, case management, follow-up); services that are 

clinically relevant to medical practice in the US. 

Interventions other than those 

specifically described in the inclusion 

criteria, including: interventions that 

primarily treat co-existing conditions, 

including pharmacotherapy.

Comparator Intervention versus non-intervention, usual care, or other 

intervention. 

Comparison groups using interventions 

other than those specifically described 

in the inclusion criteria. 

Outcomes Suicidal self-directed violence including suicide attempt and 

suicide; suicide-specific mortality. Additional secondary 

outcomes will be collected as available from studies designed 

primarily to capture suicidal self-directed violence.

For KQ2, studies need to report a measure of diagnostic 

accuracy.

Self-directed violence ideation and 

undetermined or non-suicidal selfdirected violence; other outcomes not 

listed as included.

Timing All included. No limitations.

Setting For risk assessment and intervention studies: Veteran or 

military inpatient or outpatient setting; or comparable nonVeteran/military setting.

Settings not applicable to US Veteran 

or military populations.

Study Design KQ1: Studies reporting diagnostic accuracy for methods to 

identify at-risk individuals using best evidence approach. 

Methods include risk assessment instruments and checklists 

of clinical symptoms and warning signs, for example; 

comparisons between various settings and modes of 

delivery, targeting specific populations, and other 

approaches.

KQ2: Effectiveness: randomized controlled trials (RCTs);

observational studies with comparison groups, systematic 

reviews with these study designs.

Adverse effects: RCTs, observational studies, systematic 

reviews, meta-analyses, and modeling studies; others 

considered.

KQ3: New studies of risk assessment and interventions 

specific to Veterans/military personnel.

Case reports.

Language English-language abstracts (includes English-language 

abstracts of non-English language papers) and papers.

Non English-language papers.

Data Sources Ovid MEDLINE, PubMed, PsycINFO, SocINDEX, Cochrane 

Central Register of Controlled Trials, Cochrane Database of 

Systematic Reviews, grey literature sources.

Sources not listed as included.

Search Dates Varies by key question; for questions addressed by prior 

systematic reviews, searches will include dates since the prior 

searches.

Studies published outside of the 

specified search dates.
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Study Selection Process

Importing Citations into EndNote Library

Search results were imported into the EndNote library and search characteristics (database name, 

date of search) were entered into Custom 1. 

Title/Abstract Review

All titles and abstracts were reviewed to eliminate obviously irrelevant publications. A single 

reviewer provided decision codes that were recorded in Custom 3 of the EndNote library. 

Decision codes:

R = Retrieve for full-text review

E = Exclude (not eligible for inclusion) 

B = Retrieve for Background only (not eligible for inclusion) 

Full-text Review

Two reviewers independently assessed the eligibility of references coded for full-text review. 

Each reviewer recorded a decision code. All disagreements about inclusion were resolved using a 

consensus process and/or review by the Principal Investigator (HDN). 

Exclusion Codes: 

1 = Non-English language 

2 = Ineligible country (ie, any country other than the US, UK, Canada, New Zealand, 

Australia) 

3 = Ineligible population or setting (eg, children or adolescents, patients with serious 

comorbidities such as cancer, nursing home populations, institutionalized 

populations) 

4 = Study does not involve diagnostic accuracy of suicide risk assessment (KQ 1) or a 

healthcare service intervention to prevent suicide (KQ2) 

5 = Study does not have a comparison group 

6 = Ineligible outcome 

7 = Ineligible study design (eg, case reports, case series)

8 = Ineligible publication type (eg, letter, editorial, publication available only as abstract, 

protocol without results, non-systematic review or regulatory agency analysis)

9 = Ineligible systematic review (due to scope, inclusion criteria, or limitations in 

quality) 
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APPENDIX C. CRITERIA USED IN QUALITY ASSESSMENT

Risk of Bias Assessment for Randomized Controlled Trials (RCTs): The Cochrane 

Collaboration Risk of Bias tool25

Overview 

Domain Description

Review authors’ 

judgment

Sequence generation Describe the method used to generate the allocation sequence in 

sufficient detail to allow an assessment of whether it should produce 

comparable groups. 

Was the allocation 

sequence adequately 

generated? 

Allocation 

concealment 

Describe the method used to conceal the allocation sequence in 

sufficient detail to determine whether intervention allocations could 

have been foreseen in advance of or during enrollment. 

Was allocation 

adequately concealed? 

Blinding of 

participants, 

personnel and 

outcome assessors 

Assessments should 

be made for each 

main outcome (or 

class of outcomes).

Describe all measures used, if any, to blind study participants and 

personnel from knowledge of which intervention a participant 

received. Provide any information relating to whether the intended 

blinding was effective. 

Was knowledge of the 

allocated intervention 

adequately prevented 

during the study? 

Incomplete outcome 

data 

Assessments should 

be made for each 

main outcome (or 

class of outcomes).

Describe the completeness of outcome data for each main outcome, 

including attrition and exclusions from the analysis. State whether 

attrition and exclusions were reported, the numbers in each 

intervention group (compared with total randomized participants), 

reasons for attrition/exclusions where reported, and any re-inclusions 

in analyses performed by the review authors. 

Were incomplete 

outcome data 

adequately addressed? 

Selective outcome 

reporting 

State how the possibility of selective outcome reporting was 

examined by the review authors, and what was found. 

Are reports of the 

study free of 

suggestion of 

selective outcome 

reporting? 

Other sources of 

bias 

State any important concerns about bias not addressed in the other 

domains in the tool. 

If particular questions/entries were pre-specified in the review’s

protocol, responses should be provided for each question/entry. 

Was the study 

apparently free of 

other problems that 

could put it at a high 

risk of bias? 

Specific Criteria Details for Judging Risk of Bias by Domain 

SEQUENCE GENERATION 

Was the allocation sequence adequately generated? [Short form: Adequate sequence generation?] 

Criteria for a judgment of 

‘YES’ 

(ie, low risk of bias)

The investigators describe a random component in the sequence generation process 

such as:

§ Referring to a random number table; using a computer random number generator; 

coin tossing; shuffling cards or envelopes; throwing dice; drawing of lots; 

minimization.*

*Minimization may be implemented without a random element, and this is considered 

to be equivalent to being random.
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Criteria for the judgment of 

‘NO’ 

(ie, high risk of bias) 

The investigators describe a non-random component in the sequence generation 

process. Usually, the description would involve

some systematic, non-random approach, for example:

§ Sequence generated by odd or even date of birth;

§ Sequence generated by some rule based on date (or day) of admission;

§ Sequence generated by some rule based on hospital or clinic record number.

Other non-random approaches happen much less frequently than the systematic 

approaches mentioned above and tend to be obvious. They usually involve judgment 

or some method of non-random categorization of participants, for example:

§ Allocation by judgment of the clinician;

§ Allocation by preference of the participant;

§ Allocation based on the results of a laboratory test or a series of tests;

§ Allocation by availability of the intervention.

Criteria for the judgment of

‘UNCLEAR’

(ie, uncertain risk of bias)

Insufficient information about the sequence generation process to permit judgment of 

‘Yes’ or ‘No’.

ALLOCATION CONCEALMENT 

Was allocation adequately concealed? [Short form: Allocation concealment?]

Criteria for a judgment of 

‘YES’ 

(ie, low risk of bias) 

Participants and investigators enrolling participants could not foresee assignment 

because one of the following, or an equivalent

method, was used to conceal allocation:

§ Central allocation (including telephone, web-based, and pharmacy-controlled 

randomization);

§ Sequentially numbered drug containers of identical appearance;

§ Sequentially numbered, opaque, sealed envelopes.

Criteria for the judgment of 

‘NO’ 

(ie, high risk of bias) 

Participants or investigators enrolling participants could possibly foresee assignments 

and thus introduce selection bias, such as

allocation based on:

§ Using an open random allocation schedule (eg, a list of random numbers);

§ Assignment envelopes were used without appropriate safeguards (eg, if 

envelopes were unsealed or non-opaque or not sequentially numbered);

§ Alternation or rotation; 

§ Date of birth;

§ Case record number;

§ Any other explicitly unconcealed procedure.

Criteria for the judgment of 

‘UNCLEAR’ 

(ie, uncertain risk of bias)

Insufficient information to permit judgment of ‘Yes’ or ‘No’. This is usually the case 

if the method of concealment is not described or not described in sufficient detail to 

allow a definite judgment; for example, if the use of assignment envelopes is 

described, but it remains unclear whether envelopes were sequentially numbered, 

opaque and sealed.

BLINDING OF PARTICIPANTS, PERSONNEL AND OUTCOME ASSESSORS

Was knowledge of the allocated interventions adequately prevented during the study? [Short form: 

Blinding?]

Criteria for a judgment of 

‘YES’

(ie, low risk of bias) 

Any one of the following:

§ No blinding, but the review authors judge that the outcome and the outcome 

measurement are not likely to be influenced by lack of blinding;

§ Blinding of participants and key study personnel ensured, and unlikely that the 

blinding could have been broken;

§ Either participants or some key study personnel were not blinded, but outcome 

assessment was blinded and the non-blinding of others unlikely to introduce bias.

Criteria for the judgment of 

‘NO’ 

(ie, high risk of bias) 

Any one of the following:

§ No blinding or incomplete blinding, and the outcome or outcome measurement is 

likely to be influenced by lack of blinding;
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§ Blinding of key study participants and personnel attempted, but likely that the 

blinding could have been broken;

§ Either participants or some key study personnel were not blinded, and the nonblinding of others likely to introduce bias.

Criteria for the judgment of 

‘UNCLEAR’ 

(ie, uncertain risk of bias)

Any one of the following:

§ Insufficient information to permit judgment of ‘Yes’ or ‘No’;

§ The study did not address this outcome.

INCOMPLETE OUTCOME DATA

Were incomplete outcome data adequately addressed? [Short form: Incomplete outcome data addressed?]

Criteria for a judgment of 

‘YES’ 

(ie, low risk of bias) 

Any one of the following:

§ No missing outcome data;

§ Reasons for missing outcome data unlikely to be related to true outcome (for 

survival data, censoring unlikely to be introducing bias);

§ Missing outcome data balanced in numbers across intervention groups, with 

similar reasons for missing data across groups;

§ For dichotomous outcome data, the proportion of missing outcomes compared 

with observed event risk not enough to have a clinically relevant impact on the 

intervention effect estimate;

§ For continuous outcome data, plausible effect size (difference in means or 

standardized difference in means) among missing outcomes not enough to have a 

clinically relevant impact on observed effect size;

§ Missing data have been imputed using appropriate methods.

Criteria for the judgment of 

‘NO’ 

(ie, high risk of bias) 

Any one of the following:

§ Reason for missing outcome data likely to be related to true outcome, with either 

imbalance in numbers or reasons for missing data across intervention groups;

§ For dichotomous outcome data, the proportion of missing outcomes compared 

with observed event risk enough to induce clinically relevant bias in intervention 

effect estimate;

§ For continuous outcome data, plausible effect size (difference in means or 

standardized difference in means) among missing outcomes enough to induce 

clinically relevant bias in observed effect size;

§ ‘As-treated’ analysis done with substantial departure of the intervention received 

from that assigned at randomization;

§ Potentially inappropriate application of simple imputation.

Criteria for the judgment of

‘UNCLEAR’ 

(ie, uncertain risk of bias)

Any one of the following:

§ Insufficient reporting of attrition/exclusions to permit judgment of ‘Yes’ or ‘No’ 

(eg, number randomized not stated, no reasons for missing data provided);

§ The study did not address this outcome.

SELECTIVE OUTCOME REPORTING

Are reports of the study free of suggestion of selective outcome reporting? [Short form: Free of selective 

reporting?]

Criteria for a judgment of 

‘YES’ 

(ie, low risk of bias) 

Any of the following:

§ The study protocol is available and all of the study’s pre-specified (primary and 

secondary) outcomes that are of interest in the review have been reported in the 

pre-specified way;

§ The study protocol is not available but it is clear that the published reports 

include all expected outcomes, including those that were pre-specified 

(convincing text of this nature may be uncommon).
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Criteria for the judgment of 

‘NO’ 

(ie, high risk of bias)

Any one of the following:

§ Not all of the study’s pre-specified primary outcomes have been reported;

§ One or more primary outcomes is reported using measurements, analysis 

methods or subsets of the data (eg, subscales) that were not pre-specified;

§ One or more reported primary outcomes were not pre-specified (unless clear 

justification for their reporting is provided, such as an unexpected adverse 

effect);

§ One or more outcomes of interest in the review are reported incompletely so that 

they cannot be entered in a meta-analysis;

§ The study report fails to include results for a key outcome that would be expected 

to have been reported for such a study.

Criteria for the judgment of 

‘UNCLEAR’ 

(ie, uncertain risk of bias)

Insufficient information to permit judgment of ‘Yes’ or ‘No’. It is likely that the 

majority of studies will fall into this category.

OTHER POTENTIAL THREATS TO VALIDITY

Was the study apparently free of other problems that could put it at a risk of bias? [Short form: Free of other 

bias?]

Criteria for a judgment of 

‘YES’ 

(ie, low risk of bias)

The study appears to be free of other sources of bias.

Criteria for the judgment of 

‘NO’ 

(ie, high risk of bias) 

There is at least one important risk of bias. For example, the study:

§ Had a potential source of bias related to the specific study design used; or

§ Stopped early due to some data-dependent process (including a formal-stopping 

rule); or

§ Had extreme baseline imbalance; or

§ Has been claimed to have been fraudulent; or

§ Had some other problem.

Criteria for the judgment of 

‘UNCLEAR’ 

(ie, uncertain risk of bias)

There may be a risk of bias, but there is either:

§ Insufficient information to assess whether an important risk of bias exists; or

§ Insufficient rationale or evidence that an identified problem will introduce bias.

Risk of Bias Assessment for Cohort Studies26,27

Criteria:

Initial assembly of comparable groups: consideration of potential confounders with either 

restriction or measurement for adjustment in the analysis; consideration of inception 

cohorts 

Maintenance of comparable groups (includes attrition, crossovers, adherence, 

contamination) 

Important differential loss to follow-up or overall high loss to follow-up 

Measurements: equal, reliable, and valid (includes masking of outcome assessment) 

Clear definition of interventions 

Important outcomes considered 

Analysis: adjustment for potential confounders. 

Definition of Ratings Based on Above Criteria:

Good: Meets all criteria: Comparable groups are assembled initially and maintained 

throughout the study (follow-up at least 80 percent); reliable and valid measurement 

instruments are used and applied equally to the groups; interventions are spelled out 
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clearly; important outcomes are considered; and appropriate attention to confounders in 

analysis. In addition, for RCTs, intention to treat analysis is used. 

Fair: Studies will be graded “fair” if any or all of the following problems occur, without the 

fatal flaws noted in the “poor” category below: Generally comparable groups are 

assembled initially but some question remains whether some (although not major) 

differences occurred in follow-up; measurement instruments are acceptable (although 

not the best) and generally applied equally; some but not all important outcomes are 

considered; and some but not all potential confounders are accounted for. Intention to 

treat analysis is done for RCTs. 

Poor: Studies will be graded “poor” if any of the following fatal flaws exists: Groups 

assembled initially are not close to being comparable or maintained throughout the 

study; unreliable or invalid measurement instruments are used or not applied at all 

equally among groups (including not masking outcome assessment); and key 

confounders are given little or no attention. For RCTs, intention to treat is lacking. 

Risk of Bias Assessment for Diagnostic/Screening Accuracy Studies*

Domain Description

Adequate description of 

population?

Study describes inclusion criteria for selecting patients, demographics (at least 

age), and setting (primary care versus hospital versus one other)

Non-biased selection? Study either reports enrolling (or attempting to enroll) a consecutive series of 

patients meeting inclusion criteria, or a random sample.

Adequate sample size? The study reports a sample size of 500 or more patients.

Low loss to follow-up/ missing 

data?

Was there important differential loss to follow-up or overall high loss to 

follow-up? Numbers should be given for each group.

Standardized method of risk 

factor assessment and scoring 

clearly described or referenced?

Standardized, reproducible methods of assessment and scoring must be 

reported or referenced.

Unbiased risk factor assessment 

by independent assessors?

Study describes unbiased risk factor assessment by independent assessors.

Adequate outcome measurement? Study clearly describes standardized and reproducible methods to 

identify/define the events - suicide attempt or behavior - in the entire 

population of eligible participants regardless of initial risk assessment.

Unbiased outcome measurement 

by independent assessors?

Study clearly describes unbiased methods to identify/define the events - suicide 

attempt or behavior - by independent assessors.

Adequate accounting for potential 

confounders?

Potential confounders are accounted for by a comparable control group or 

statistical methods of adjustment.

*Modified from Hayden et al 2006 and Harris et al 2001.26,28
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APPENDIX D. PEER REVIEW COMMENTS/AUTHOR RESPONSES

Reviewer 

Number Comment Response

Are the objectives, scope, and methods for this review clearly described?

3 No - The key questions are very confusing - unclear why effectiveness vs. 

efficacy; key question 3 and search strategy particularly unclear.

Key Questions 1 and 2 use the term “effectiveness” rather than 

“efficacy” to reflect broader study inclusion criteria relevant to 

studies conducted in clinical populations and studies evaluating 

population-level interventions. More narrowly inclusive efficacy 

studies would also be included in the review. The revision uses both 

terms in order to clarify this. 

Key Question 3 addresses research gaps based on the synthesis of 

findings for Key Questions 1 and 2. The studies cited in this section 

were also identified from the searches conducted for KQ 1 and 2, but 

were selectively used to highlight areas for future research that 

address the research gaps. This information has been clarified in the 

revision. In addition, tables describing relevant ongoing studies 

identified from our grey literature search have been added to the 

revision.

4 Yes Noted.

5 Yes Noted.

6 Yes Noted.

7 Yes Noted.

8 Yes Noted.

9 No - See narrative review in the section for "Additional suggestions or 

comments". My greatest concern is that the criteria for selecting studies and 

publication for inclusion is not specified in sufficient detail to allow another 

investigator to follow the procedures that are specified and wind up with 

similar evidence tables.

Search strategies and inclusion/exclusion criteria for selecting studies for 

the systematic review are described in the appendix according to a 

standard format for systematic reviews. See above clarification 

regarding the search for studies included for Key Question 3.

Are there any published or unpublished studies that we may have overlooked?

3 Yes - Per page 11 unclear by interventions that included healthcare 

services....were not included. This is particularly odd as review is to focus on 

effectiveness.

The scope of this review included healthcare service interventions other 

than studies of interventions to primarily treat co-conditions, as well as 

studies of pharmacotherapy. 

4 Yes - There are multiple relevant assessment studies and clinical trials 

currently underway funded by the Military Suicide Research Consortium, 

beyond VHB and WtoH, not referenced. Details are available at 

Two tables of relevant ongoing studies were added to the revision 

including studies from the MSRC website.
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Reviewer 

Number Comment Response

www.msrc.fsu.edu.

5 Yes - I recently reviewed a paper using PHQ9 depression questionnaire data 

to predict subsequent suicidal behavior in a VA sample. I believe that paper 

is now accepted. I'd be happy to contact the journal for more information.

This reviewer graciously provided this study and it was considered for 

inclusion; however, the study was not eligible because it is not yet 

published and does not report a measure of diagnostic accuracy.

6 No Noted.

7 Yes - There are at least one or two studies funded by VA and recently 

completed that are either in the publishing pipeline or the 'null results' file 

cabinet---e.g., Stephen Dobscha's recent work in primary care. I realize it's 

often hard to find these, but were these considered?

These studies will be added to the revision if they are available and meet 

inclusion criteria.

8 Yes - These may have been reviewed and not included as citations in the 

general text (not as selected studies for review), but I wondered if they may 

help update citation #12, which seems a bit dated. 

1. Denneson LM, Teo AR, Ganzini L, Helmer DA, Bair MJ, Dobscha SK. 

Military Veterans' Experiences with Suicidal Ideation: Implications for 

Intervention and Prevention. Suicide & Life-Threatening Behavior. 2015 

Aug 1; 45(4):399-414.

2. Dobscha SK, Denneson LM, Kovas AE, Teo A, Forsberg CW, Kaplan 

MS, Bossarte R, McFarland BH. Correlates of suicide among veterans 

treated in primary care: case-control study of a nationally representative 

sample. Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:853-60.

These papers include authors who are investigators for the systematic 

review. The references were added to the revision as contextual 

information in the introduction section.

9 Yes - See narrative review in the section for "Additional suggestions or 

comments."

See responses below.

Is there any indication of bias in our synthesis of the evidence?

3 No Noted.

4 No Noted.

5 No Noted.

6 No Noted.

7 No Noted.

8 No Noted.

9 No Noted.

Additional suggestions or comments can be provided below. If applicable, please indicate the page and line numbers from the draft report.

3 Key questions confusing - grouping of effectiveness and adverse events -- are 

adverse events actually the outcome of interest (suicide). Few efficacy 

studies have been completed so again it is unclear why we would be moving 

See above related responses.
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Number Comment Response

to effectiveness. Number of studies in progress not identified - (e.g., lithium, 

blister packaging) which leads to even greater confusion are how data was 

identified for Key Question #3

4 Overall this is a well written review summarizing relevant studies concisely. 

There are places where additional detail is needed, terminology could be 

clarified, or presentations of study findings are not as clear as one would like. 

These points are summarized below in order of appearance in the manuscript.

Noted.

Executive Summary, page 1 line 19, suicide rates went up among all of the 

services, not just the Army. While Army rates increased the most, and the 

overall numbers of soldier suicides were larger than any other service due to 

the Army being the largest of the services, the impact on Sailors, Airmen, 

and Marines should not be overlooked. Page 3, line 16, the term “commit 

suicide” is not consistent with current nomenclature. “Died by suicide” or 

simply “suicide” are the preferred terms. If this was the term used in the 

referenced study and there is a reason the authors believe it should be 

maintained in the review then please place it in quotes. 

Executive Summary: The point that suicide rates increased among all of 

the services, not just the Army, has been added to the revision. The term 

“commit suicide” has been changed throughout the report.

Background, page 7 line 40, see previous comment regarding suicide rates in 

the other services. Line 42, I see the point being made but the wording is 

somewhat awkward and one could misinterpret the statistics to mean that 

Veteran rates increased from 20% of the U.S. population to 60%. Starting 

line 48, although STARRS includes “Army” in the title many people don’t 

realize that it is a study focusing just on soldiers and not members of the 

other services. I suggest making that point clear and at other places in the 

manuscript where the study is discussed.

One possible explanation for differences in STARRS results, particularly 

around the impact of deployments on suicide risk, is that the population 

sampled differs from the other large military cohort studies that have been 

recently published. It would be important to make that point in the review.

Background: The “20% to 60%” rise in suicide rate phrase was deleted 

in the revision to avoid misinterpretation. Additional information was 

added to the sentence describing the Army STARRS study to make it 

clear that it is specifically about Army soldiers, not members of the 

other services. 

The additional point about differences in STARRS results would require 

discussion of the risk factors described in other large military cohort 

studies, which is outside the scope of the background section of this 

report.

 

Current practices, page 8 beginning line 30, there is no reference to the Zero 

Suicide initiative results from the Henry Ford Healthcare System in Detroit. 

They have published results indicating dramatic decreases in suicide deaths 

among their patients being treated for depression. Granted, this work was not 

in primary care, but it was still conducted throughout a large healthcare 

system treating approximately 200,000 individuals and seems relevant to cite 

here. I’m further confused by the lack of mention of that study here, since it 

is included on page 35 beginning line 52.

The Henry Ford Healthcare System Initiative is not described in the 

background because it was included as a study in the systematic review. 

Therefore, it is described in the results section.
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Reviewer 

Number Comment Response

Topic Development, page 9 line 22, again STARRS only includes data from 

Army soldiers. Results will likely generalize to other services and be 

applicable to Veterans, but those are empirical questions and it should not be 

assumed a priori that is the case.

Methods: Additional information was added to the sentence describing 

the Army STARRS study to make it clear that it is specifically about 

Army soldiers.

In the description of the first individual level RCT to reduce suicide-specific 

outcomes on page 39 line 18 the intervention is referred to as “the cognitive 

behavioral therapy group”, but it is individual psychotherapy. Perhaps the 

authors meant “condition” rather than group, but since they referred to TAU 

as including group therapy in the previous line this reference to the treatment 

condition is confusing and should be clarified.

Results: In the results section, the term “group” usually refers to 

comparison groups (treatment versus usual care); however, this could be 

confusing because treatment often included group therapy. The term 

“group” is now explicitly referred to as the “comparison group” when 

used in this context.

The points made on page 47, beginning line 52 regarding the effectiveness of 

the Air Force Suicide Prevention Program are valid in general. But it seems 

somewhat disingenuous to criticize evaluations of the that program for not 

having comparison data to concurrent groups not receiving the intervention 

since it was a population-level intervention implemented in the entire Air 

Force. I suppose someone could have tried to create a demographically 

comparable sample from one of the other services that did not implement 

their own prevention program during the same time period, and compared 

results to that group, but the absence of such data should not be considered a 

limitation of the Air Force program evaluations.

The point about concurrent comparison data for the Air Force Suicide 

Prevention Program is intended to indicate evidence gaps and potential 

future research which is the purpose of Key Question 3.

Use of the term “commit suicide” appears again on page 50, line 34. See 

previous comment regarding this issue for suggestions on how to address it.

See previous response regarding edits to statements that use the term 

“commit suicide.”

I leave it to the authors to determine the most appropriate place to add a 

discussion of balancing sensitivity and specificity in suicide risk assessment 

research. The authors define the terms and report the values for all studies 

which provided the statistics, but do not provide adequate context for readers 

to evaluate the presented data. This is a vital question for clinicians wishing 

to select specific measures to use in their practices, or more importantly for 

VA to consider in broad policy recommendations. This systematic review 

poses a good opportunity to address this issue in ways that can actually 

inform clinical practice.

Summary and Discussion: Since the primary goal of risk assessment is 

to identify individuals at risk for suicide, sensitivity measures were 

prioritized in the report. This statement and a new figure summarizing 

the sensitivity results for each study have been added to the revision.

5 General comment – The review is thorough, balanced, and clearly presented. 

I have no significant concerns regarding the methods, selection of evidence, 

or interpretation.

Noted.

Specific comments/suggestions:

1) I think the presentation would be clearer if the authors adhered to the 

traditional classification of prevention programs: primary or universal 

Regarding whether studies are primary, secondary, or tertiary 

prevention: There are too few studies to create additional sub-sections of 

this material in the report, however, details of the study participants are 
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Reviewer 

Number Comment Response

prevention for the entire population, secondary or selective prevention for 

those at increased risk and tertiary or indicated prevention for those already 

affected. The author’s current scheme appears (to me) to lump together 

secondary and tertiary prevention interventions. I believe that health systems 

should (and usually do) distinguish between these two needs. And the 

evidence in these two areas is quite distinct (much clearer evidence for 

effectiveness of tertiary prevention to prevent repeat suicide attempt than 

secondary prevention to prevent attempt in those at increased risk).

described in the text and table.

2) When presenting data regarding screening or case-finding tools, I would 

emphasize sensitivity and PPV (and de-emphasize specificity). Specificity is 

markedly dependent on prevalence, and therefore much less generalizable 

across settings. PPV is also much more relevant to health system decisionmakers (What proportion of the people we would identify would be true 

cases?).

See above related response.

3) The discussion of screening or case-finding methods should probably 

distinguish between studies using some independent (and, ideally, 

prospective) ascertainment of suicidal behavior vs. those assessing risk 

factors and retrospectively assessing outcomes in the same cross-sectional 

interview. The latter method seems (at least to me) much more subject to 

bias.

The methods related to identifying at-risk individuals are described in 

more detail in the table. Additional points about methods have been 

added to the text as well.

4) Even if the authors choose not to use the primary/secondary/tertiary 

scheme, the discussion of “individual-directed” interventions should certainly 

distinguish between those for at-risk populations (e.g. first-episode 

psychosis) and those for people with recent suicide attempts or suicidal

behavior.

The participants included in each study are detailed in the text and 

tables. 

6 Exec Summary – This section is so important and we know many read this 

over any other level of detail. Is it possibility to include references for the 

percentages cited page 1? Considering the high level scrutiny of the topic, 

etc.

According to the style template, references are not included in the 

Executive Summary.

Page 2 – data abstraction and quality assessment, “pre-piloted” database not 

clear what that was referencing or is it important for exec summary? Same 

paragraph – suggest last sentence: ... resolved through consensus – add 

process including all reviewers (as consensus process alone does not provide 

method for actual resolution).

Edits to the data abstraction and quality assessment section have been 

made accordingly.

Page 3 – Line 22 included in the previous review – Previous review was not 

defined as far as I read in the exec summary exactly – are you referring to 

first sentence which includes three reviews (plural) or a specific?

The statement on page 3 refers to one of the previous reviews. To 

improve clarity, “a VA ESP review” was added to the statement. 
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Reviewer 

Number Comment Response

Page 3 – Last paragraph line 58. No studies evaluated adverse effects. How 

is that possible if they were RCTs?

The statement about adverse effects was modified to, “No studies 

specifically evaluated adverse effects of the interventions.” 

Page 5 – Discussion – Would you like to define “fair” predictive accuracy. Fair diagnostic accuracy is described in a table in the Methods section 

(ROC AUC =0.70 to 0.79). This description was moved to the Executive 

Summary in order to support the discussion point.

Page 6 – Conclusions – does it make sense to also acknowledge the inherent 

challenges in the work? This is just a conceptual discussion; I think agencies 

are working towards improvements (STARRS, the suicide prevention 

database, CSP trial of lithium).

This point about inherent challenges in the work has been added to the 

conclusions. 

Page 7 – Background – is there an opportunity end of first paragraph to also 

speak about risk from recent healthcare encounters/timing issues; may be 

appropriate in Page 8 Current Practices section instead/also. I really 

appreciate the Current Practices section.

The point about suicide in relationship to recent healthcare encounters 

has been added to the Current Practices section.

Page 10 – Why is the alpha D, E, F used under Q1 and C, D under Q2? The lettering for sub-questions was incorrect in the draft because of an 

auto formatting issue. This has been corrected in the current version.

Page 45 – I like the discussion about the risk assessment issues. Somewhat 

related is an effort undertaken by NIH with VA and DoD to define common 

data elements for suicide prevention research 

http://www.research.va.gov/resources/suicide_prevention.cfm - describes the 

request; elements have been published in the PhenX toolkit and we are at 

least encouraging their use. This doesn’t answer the need for more 

psychometric, but supports the idea of cde’s for the topic going forward. 

Maybe this could be noted in the discussion?

The point about common data elements has been added to the 

discussion.

7 No comments. Noted.

8 Page 10. It seems odd that the structure of Key Questions 1 and 2 are not the 

same, as they ask about very similar things. For KQ1, there is a sub-question 

on effectiveness of methods and a separate sub-question on adverse effects; 

but for KQ2, both effectiveness and adverse effects are addressed in a single 

sub-question. The way studies on effectiveness and adverse effects are laid 

out in the text are similar across both Key Questions, so it is not clear why 

the Key Questions are set up differently. If given a choice, I would prefer the 

2 separate questions, as in KQ1, since this seems to fit slightly better with the 

layout of the text.

To improve consistency and efficiency, “adverse effects” was combined 

with “effectiveness” for both Key Questions.

Also, under these questions on page 10, the lettering of the sub-questions 

seems to be out of order --where are A) and B)?

The lettering for sub-questions was incorrect in the draft due to an auto 

formatting issue. This has been corrected in the current version.

In the paragraph starting on page 10, line 36, it says that adverse effects For the purposes of study selection for the systematic review, non-
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Number Comment Response

include any outcomes "that are not beneficial to the patients" suggesting that 

something with a neutral outcome -- one that does not help or hurt the patient 

-- would be considered adverse. Is this correct?

beneficial outcomes would be evaluated for adverse effects, but the 

clinical relevance of a specific outcome would need to be considered as 

well. Some outcomes may have a neutral effect on some patients and an 

adverse effect on others.

On page 11, line 19, it seems there is either a word missing or an extra word 

inserted -- not sure which it is, and the sentence is unclear.

The sentence on page 11 was clarified in the revision.

On page 12, line 21: What is it about these studies made them too 

heterogeneous for inclusion in a meta-analysis? The sample? The 

instruments? The outcome measures? The risk of bias?

Several factors made the studies too heterogeneous for meta-analysis; 

these factors have been added to the sentence in the revision 

(participants, interventions, measures, outcomes).

On page 12, figure 2: under the box 'Excluded = 438 references', what are the 

ineligible systematic reviews? The criteria for judging the eligibility of 

systematic reviews for inclusion were not mentioned previously.

Inclusion criteria for systematic reviews have been added to the methods 

section in the revision.

It is not clear why the literature reviews for both Key Questions were split 

into subsections based on whether the studies cited were used in the previous 

reviews or not; What was the justification for this? (apologies if I missed it in 

the text.) If it is being used to highlight changes in the literature over time, I 

think that focus needs to be made more explicit; maybe in a short summary 

section for each of the Key Questions.

Since this report is an update of parts of 3 earlier VA ESP systematic 

reviews, the results for each Key Question begin with a brief summary 

of relevant previous findings. Details of the studies are also included in 

tables. The revision provides a more explicit rationale for presenting the 

results this way, which is to consolidate the evidence.

Page 16, line 57: Should 'analysis' be 'analyses' since it is referring to work 

across studies?

Here, “regression analysis” refers to the methodological approach, not 

necessarily each study’s analysis. 

Page 25, Table 1.3: If you are generating a table that lists the various 

measures of risk for SDV or suicide found in the selected studies, is there a 

need for the main citation for each measure to be included in the table as 

well, so a reader could know where to check on the key characteristics (i.e., 

reliability and validity) of specific measures? This basically adds another 

column to the table.

Additional citations for the risk instruments have been added to the 

Table as described by the reviewer.

Page 50, line 6: Sentence does not seem complete. The sentence on page 50 directs readers to tables.

Could there be a summary paragraph at the end that highlights the advances 

made since the time of the previous reports, particularly with respect to the 

gaps that were previously identified?

Although the suggestion for a summary is helpful, few studies from the 

previous reviews addressed the Key Questions of this review, and these 

are briefly described at the beginning of each of the results sections.

9 There must be concerns about the specification of the criteria for inclusion of 

studies in the review as specified on page 11, rows 7-17.

The text indicates “eligible studies included populations of ... nondemographically comparable non-Veteran/military adults aged 18 and older 

....” The statement about studies that “included ... demographically 

The inclusion criteria, “demographically comparable nonVeteran/military adults...” are intended to be inclusive. The exclusion 

criteria are more explicit and indicate that highly selective samples that 

would not be representative of military/Veteran populations would be 

excluded, including patients with other serious co-morbidities such as 
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Number Comment Response

comparable non-Veterans military adults” is vague. Does it mean that it 

included studies with any demographically comparable individuals or does it 

mean study that included only these individuals? What dimensions were 

included in the comparison? Without this information, it would be impossible 

for anyone to replicate the search and selection processes in a reliable way, or 

for anyone to evaluate the sensitivity of the process. If it does not specify 

methods that could allow replication, the article is of limited value as a 

systematic review.

In a similar way, the text indicates that “(s)tudies enrolling participants from 

dissimilar populations were not included because they are less applicable to 

the target population of this review (eg, children and adolescents; individuals 

with serious psychiatric or medical comorbidities such as schizophrenia or 

cancer, and institutionalized populations). Alas, service members and 

Veterans can get serious psychiatric or medical illnesses such as 

schizophrenia and cancer, and they can get institutionalized. A substantial 

proportion of suicides among Veterans occurs among those with one serious 

psychiatric comorbidity, depression, and another large proportion occurs in 

those with schizophrenia or bipolar disorder or PTSD. Excluding these 

populations limits the potential utility of the review. In fact, it is unlikely that 

there is any study of suicide prevention that did not include individuals with 

“serious psychiatric ...illnesses.” The exclusion should be reconsidered or, at 

least, the text should be modified to indicate exactly what conditions were 

exclusionary.

Most of the concerns discussed here are related to the sensitive of the 

methods used for identifying studies for inclusion. However, there may also 

be concerns about the specificity. One study (Galfavy HC, Oquendo MA, 

Mann JJ. Act Psychiatrica Scand 117: 244-252, 2008) discussed in detail on 

pages 17 and 18 included only patients with a major depressive episode and a 

diagnosis of major depressive disorder or bipolar disorder. All of the patients 

in this study had “serious psychiatric illnesses”. Why was this paper, but not 

others, included?

The text states that eligible studies included populations from the US, UK, 

Canada, New Zealand, and Australia. Again, does this mean that for 

inclusion, the studies included any individuals from these countries, or that 

they included only individuals from these countries. The stated rationale for 

including these countries was that they were “chosen because of their 

advanced cancer, etc. Even though military/Veterans also experience 

serious illness, this report focuses on prevention in a broader population.

Since depressive disorders, including many undiagnosed cases, are fairly 

common, studies conducted among depressed participants were 

included. It would be unmanageable to list all possible other exclusions.

The criteria are described in the Appendix and more details have been 

added to the revision to address additional questions of the reviewer.

The inclusion of studies performed in the selected countries is consistent 

with the previous reviews for which this report serves as an update. 

The use of the term “diagnostic accuracy study” is a category of study 

design that applies to studies for Key Question 1. While this may not be 

the best description for these studies, it is the appropriate term for the 

type of study. The revision minimizes its use to reduce confusion. 
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Reviewer 

Number Comment Response

similarities to the US in terms of healthcare services as well as their 

involvement in the Operation Enduring Freedom/ Operation Iraqi Freedom 

(OEF/OIF) conflicts.” The extent to which healthcare services in the UK, 

Canada, New Zealand, and Australia are similar to those in the US could be a 

matter of debate. Moreover, the selection of these countries appears arbitrary. 

There has been a substantial body of research on suicide prevention in other 

countries that participated in OEF/OIF including Germany, Italy, and the 

Scandinavian countries. It is not clear why the authors excluded them. 

Moreover, the restriction to the specified countries excluded information that 

is clearly relevant to military populations, e.g., findings from Israeli 

experience about soldier’s access to firearms when they were not on duty 

(Lubin G, Webeloff N, Halperin D, et al, Suicide and Life Threatening 

Behavior 40: 421-424, 2010).

The text included the statement, “For Key Question 1, included studies 

evaluated the diagnostic accuracy of methods ....” It is not clear if including 

the word “diagnostic” is appropriate. This issue recurs elsewhere (e.g., page 

5, line 23).

There are a number of studies that appear salient but are not included in the 

systematic review. This is of concern for two reasons. First, the findings are 

not included in the information presented to the readers. Second, and more 

important, their absence raises questions about the sensitivity and reliability 

of the processes used for identifying relevant studies.

Two publications (1

Kessler RC , Warner CH, Ivany C, et al. JAMA 

Psychiatry 72:49-57; and 2

Simon GE, Rutter CM, Peterson D, et al, 

Psychiatric Services 64: 1195-1202, 2013) are included in the references 

(Numbers 74 and 76 on page 61, respectively) and cited on page 46 in the 

discussion for key question #3. However, they are not included in the

evidence tables or the discussion related to key question #1. This is a 

significant omission, not only because the findings from these studies are 

important, but because their absence suggests that the evidence tables may be 

incomplete.

Findings from one VA study (3

Ganzini L, Denneson LM, Press N, et al, 

Journal of General Internal Medicine 28, 1215-1221, 2013) are highly 

important for inclusion in the evidence base for key question #1, and for 

framing the discussion. Why wasn’t this study included?

Although the studies identified by the reviewer are relevant to this 

review, studies that did not meet inclusion criteria for Key Questions 1 

and 2 were not included in the evidence tables. Since Key Question 3 

focuses on future research to address evidence gaps, inclusion criteria 

are broader, and some of these studies are described under the KQ3 

section.

The inclusion criteria state that studies of interventions to primarily treat 

co-existing conditions, as well as studies of pharmacotherapy, were not 

included (page 11). The scope of the review was determined by the 

sponsor and technical expert panel members.

The review includes studies of interventions that reported suicide and 

other suicidal self-directed violence as outcomes; studies reporting other 

outcomes were excluded.

Regarding specific studies mentioned by the reviewer:

1. Kessler RC, Warner CH, Ivany C, et al. Predicting suicides after 

psychiatric hospitalization in US Army soldiers: the Army Study To 

Assess Risk and rEsilience in Servicemembers (Army STARRS). 
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Number Comment Response

After reading the manuscript, I identified three studies that, from my 

perspective, should have been included in the evidence table and discussion 

related to key question #2 (4

Beautrais AL, Gibb SJ, Faulkner A, et al. British 

Journal of Psychiatry. 197:55-60, 2010; 5

Currier GW, Fisher SG, Caine ED. 

Academic Emergency Medicine. 17:36-43, 2010; 6

Alexopoulos GS, 

Reynolds CF 3rd, Bruce ML, et al American Journal of Psychiatry. 166:882-

90, 2009). Why weren’t these studies included? Does their absence suggest 

that the search strategy and/or the inclusion/exclusion criteria for reviewing 

publications should be revised?

Without explicitly stating that it does so, and without specifying relevant 

inclusion/exclusion criteria, the review appears to have excluded somatic 

treatments from the evidence table and discussion. Some of these 

publications (e.g., 7

Price RB, Iosifescu DV, Murrough JW, et al Depression 

& Anxiety. 31:335-43, 2014; 8

Cipriani A, Hawton K, Stockton S, et al BMJ. 

346:f3646, 2013; 9

Khan A, Khan SR;,Hobus J, et al Journal of Psychiatric 

Research. 45:1489-96, 2011; 1

Oquendo MA, Galfalvy HC, Currier D, et al 

American Journal of Psychiatry. 168:1050-6, 2011; 11Grunebaum MF, Keilp 

JG, Ellis SP, et al Journal of Clinical Psychiatry. 74(9):872-9, 2013; 12Zisook 

S, Kasckow JW, Lanouette NM, et al Journal of Clinical Psychiatry. 71:915-

22, 2010) may have been excluded because they focus on treatment of 

patients with specific mental disorders; this exclusion reinforces concerns 

about whether the exclusion of studies based in populations characterized by 

mental disorders limits the value of the review. However, a publication from 

VA investigators focused on somatic treatment of suicidality, rather than 

specific mental health conditions, albeit in patients with mental disorders or 

TBI (13George MS, Raman R, Benedek DM, et al Brain Stimulation. 7:421-

31, 2013). It is not clear why this paper was excluded. Perhaps, related to this 

issue, the section related to key question #2 uses the term “Healthcare 

Services Intervention”. What is a “healthcare services intervention”? Does 

the definition exclude somatic treatments?

JAMA Psychiatry. 2015 Jan;72(1):49-57. 

This study was published after the initial literature search and 

has been included under Key Question 1 in the revision.

2. Simon GE, Rutter CM, Peterson D, et al. Does response on the 

PHQ-9 Depression Questionnaire predict subsequent suicide 

attempt or suicide death? Psychiatr Serv. 2013 Dec 1;64(12):1195-

202.

This study does not meet inclusion criteria for Key Question 1 

because it does not report measures of accuracy (ie, sensitivity 

and specificity) and these measures cannot be calculated from 

the reported data. Since it is a relevant study and future 

research to determine its sensitivity and specificity would be 

useful, the study is described in Key Question 3. 

3. Ganzini L, Denneson LM, Press N, et al. Trust is the basis for 

effective suicide risk screening and assessment in Veterans. J Gen 

Intern Med. 2013 Sep;28(9):1215-21. 

This study does not meet inclusion criteria.

4. Beautrais AL, Gibb SJ, Faulkner A, Fergusson DM, Mulder RT. 

Postcard intervention for repeat self-harm: randomised controlled 

trial. Br J Psychiatry. 2010 Jul;197(1):55-60. 

The outcome of this study is self-harm, but the study did not 

differentiate suicidal or non-suicidal self-harm and it was not 

included in this review.

5. Currier GW, Fisher SG, Caine ED. Mobile crisis team intervention 

to enhance linkage of discharged suicidal emergency department 

patients to outpatient psychiatric services: a randomized controlled 

trial. Acad Emerg Med. 2010 Jan;17(1):36-43.

The outcome of this study is improved clinical contact after 

discharge, not suicidal self-directed violence. Therefore, it was 

not included in this review. 

6. Alexopoulos GS, Reynolds CF 3rd, Bruce ML, Katz IR, Raue PJ, 

Mulsant BH, Oslin DW, Ten Have T; PROSPECT Group. Reducing 

suicidal ideation and depression in older primary care patients: 24-

month outcomes of the PROSPECT study. Am J Psychiatry. 2009 

Aug;166(8):882-90.

Results of this trial (PROSPECT) were reported in a separate 

publication in the previous systematic review. In the revision, 

this reference was added under the same trial in the table with 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Reviewer 

Number Comment Response

the other reference (Gallo).

References 7-12 concern therapies that are not included in this 

systematic review (see Appendix B for inclusion/exclusion criteria): 

7. Price RB, Iosifescu DV, Murrough JW, et al. Effects of ketamine on 

explicit and implicit suicidal cognition: a randomized controlled 

trial in treatment-resistant depression. Depress Anxiety. 2014 

Apr;31(4):335-43.

Study of ketamine using the Implicit Associations Test as an 

outcome measure. 

8. Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the 

prevention of suicide in mood disorders: updated systematic review 

and meta-analysis. BMJ. 2013 Jun 27;346:f3646. 

A systematic review of lithium for suicide prevention in people 

with mood disorders. 

9. Khan A, Khan SR, Hobus J, et al. Differential pattern of response in 

mood symptoms and suicide risk measures in severely ill depressed 

patients assigned to citalopram with placebo or citalopram 

combined with lithium: role of lithium levels. J Psychiatr Res. 2011 

Nov;45(11):1489-96.

A study of lithium.

10. Oquendo MA, Galfalvy HC, Currier D, et al. Treatment of suicide 

attempters with bipolar disorder: a randomized clinical trial 

comparing lithium and valproate in the prevention of suicidal 

behavior. Am J Psychiatry. 2011 Oct;168(10):1050-6.

A study of lithium.

11. Grunebaum MF, Keilp JG, Ellis SP, et al. SSRI versus bupropion 

effects on symptom clusters in suicidal depression: post hoc 

analysis of a randomized clinical trial. J Clin Psychiatry. 2013 

Sep;74(9):872-9. 

A study of SSRI vs. bupropion. 

12. Zisook S, Kasckow JW, Lanouette NM, et al. Augmentation with 

citalopram for suicidal ideation in middle-aged and older 

outpatients with schizophrenia and schizoaffective disorder who 

have subthreshold depressive symptoms: a randomized controlled 

trial. J Clin Psychiatry. 2010 Jul;71(7):915-22. 

A study of citalopram.

13. George MS, Raman R, Benedek DM, et al. A two-site pilot 
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Reviewer 

Number Comment Response

randomized 3 day trial of high dose left prefrontal repetitive 

transcranial magnetic stimulation (rTMS) for suicidal inpatients. 

Brain Stimul. 2014 May-Jun;7(3):421-31. 

Outcome measure is suicidal thinking, not suicidal self-directed 

violence.

3. The manuscript includes a table of previous systematic reviews of 

interventions for suicide prevention. However, it appears incomplete. The 

authors should consider adding other recently published systematic reviews 

focusing on specific aspects of suicide prevention. (1Milner AJ, Carter G, 

Pirkis J. et al. Br J Psychiatry. 206:184-90, 2015; 2Cuijpers P, de Beurs DP, 

van Spijker BA, et al J Affect Disord.144:183-90, 2013; 3Lapierre S, 

Erlangsen A, Waern M, et al. Crisis. 32:88-98, 2011; 4Brown GK, Green KL. 

American Journal of Preventive Medicine S209-S215, 2014; 5van der FeltzCorrelis CM, Sachiapone M, Postuvan V, et al. Crisis 22:319-33, 2011.)

The systematic reviews cited by the reviewer include the following:

1. Milner AJ, Carter G, Pirkis J, Robinson J, Spittal MJ. Letters, green 

cards, telephone calls and postcards: systematic and meta-analytic 

review of brief contact interventions for reducing self-harm, suicide 

attempts and suicide. Br J Psychiatry. 2015 Mar;206(3):184-90. 

This systematic review does not meet inclusion criteria.

2. Cuijpers P, de Beurs DP, van Spijker BA, Berking M, Andersson G, 

Kerkhof AJ. The effects of psychotherapy for adult depression on 

suicidality and hopelessness: a systematic review and meta-analysis. 

J Affect Disord. 2013 Jan 25;144(3):183-90. 

This systematic review does not include any studies with 

suicidal self-directed violence as outcomes.

3. Lapierre S, Erlangsen A, Waern M, et al. A systematic review of 

elderly suicide prevention programs. Crisis. 2011;32(2):88-98.

This systematic review does not meet inclusion criteria.

4. Brown GK, Green KL. A review of evidence-based follow-up care 

for suicide prevention: where do we go from here? Am J Prev Med. 

2014 Sep;47(3 Suppl 2):S209-15.

This paper is not a systematic review, but describes key papers 

from previously published systematic reviews. This publication 

was used to help identify additional studies that the literature 

search may not have captured.

5. van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, et al. Best 

practice elements of multilevel suicide prevention strategies: a 

review of systematic reviews. Crisis. 2011;32(6):319-33.

This paper is not a systematic review, but describes key papers 

from previously published systematic reviews. This publication 

was used to help identify additional studies that the literature 

search may not have captured.

4. The literature on treatments such as transcranial magnetic stimulation and 

ketamine raise questions about whether suicidality, regardless of the 

underlying diagnosis of a mental health condition, can be a target for somatic 

Somatic treatment is outside the scope of this review.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

103

Reviewer 

Number Comment Response

treatment. This issue should be discussed, either by including relevant studies 

in the evidence table for key question #2 or including it in the discussion for 

key question #3.

5. The discussion of Cognitive Behavioral Therapy (CBT) should distinguish 

between CBT directed toward suicidality as an indication (e.g., Rudd MD, 

Bryan CJ, Wertenberger EG, et al. American Journal of Psychiatry 172: 

4441-449, 2015; Brown GK, Ten Have T, Henriques GR, et al, JAMA 294, 

563-570, 2005) versus the large majority of other studies that evaluated CBT 

targeting an underlying mental health condition. It might acknowledge that 

the impact on suicide-related behaviors of CBT directed toward specific 

conditions has been variable, but the impact of the specific intervention 

Cognitive Therapy for Suicide Prevention has, thus far, been consistent. 

This systematic review did not evaluate CBT for other indications and is 

unable to draw this conclusion.

6. On page 4, the review includes the statement, “few studies have evaluated 

the effectiveness of preventive interventions in individuals at earlier stages of 

the suicide pathway.” The review would have been strengthened by a 

discussion of rates of suicide-related behaviors across population, estimates 

of effect sizes for different types of interventions, the sample sizes that would 

be necessary to achieve adequate statistical power in an intervention study, 

and the anticipated costs of the research that would be needed.

This information would be interesting and relevant, but is outside the 

scope of this review.

7. In discussing trends in suicide rates for Veterans and service members, it 

would be useful to include information about Veterans receiving health care 

services from VA and other Veterans, as well as the differences between the 

two groups.

Statistics regarding suicide trends among Veterans within and outside 

VA healthcare are provided as available from published sources.

8. Page 7 line 43: Consider changing “Female Veterans are at especially high 

risk ...” to “Female Veterans are at especially high risk relative to other 

women ...”

This sentence was revised as suggested.
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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APPENDIX E. EXCLUDED REFERENCES 

Exclusion Codes: Reasons for Exclusion*

1 = Non-English language 

2 = Ineligible country (ie, any country other than the US, UK, Canada, New Zealand, Australia)

3 = Ineligible population or setting (eg, children or adolescents, patients with serious 

comorbidities such as cancer or schizophrenia, nursing home populations, institutionalized 

populations) 

4 = Study does not involve diagnostic accuracy of suicide risk assessment (KQ 1) or a healthcare 

service intervention to prevent suicide (KQ2) 

5 = Study does not have a comparison group 

6 = Ineligible outcome 

7 = Ineligible study design (eg, case reports, case series) 

8 = Ineligible publication type (eg, letter, editorial, publication only available as an abstract, 

protocol without results, non-systematic review or regulatory agency analysis)

9 = Ineligible systematic review (due to scope, inclusion criteria, outcomes, or limitations in 

quality) 

*Some citations had multiple reasons for being ineligible; only one exclusion code is listed in the 

table.

Citation

Key 

Question

Exclusion 

Code

Abidin Z, Davoren M, Naughton L, Gibbons O, Nulty A, Kennedy HG. Susceptibility (risk and protective) 

factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments 

START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services. BMC Psychiatry. 

2013;13(Issue):197.

KQ1 6

Acosta FJ, Vega D, Torralba L, et al. Hopelessness and suicidal risk in bipolar disorder. A study in clinically 

nonsyndromal patients. Compr Psychiatry. 2012;53(Issue):1103-1109.

KQ1 2

Agosti V, Chen Y, Levin FR. Does Attention Deficit Hyperactivity Disorder increase the risk of suicide attempts? 

J Affect Disord. 2011;133(Issue):595-599.

KQ1 4

Albright G, Goldman R, Shockley KM, McDevitt F, Akabas S. Using an Avatar-Based Simulation to Train 

Families to Motivate Veterans with Post-Deployment Stress to Seek Help at the VA. Games for Health Journal. 

2011;1(Issue):21-28.

KQ2 6

Alonzo D, Stanley B. A novel intervention for treatment of suicidal individuals. Psychiatr Serv. 

2013;64(Issue):494.

KQ2 6

Alonzo D, Thompson RG, Stohl M, Hasin D. The influence of parental divorce and alcohol abuse on adult 

offspring risk of lifetime suicide attempt in the United States. Am J Orthopsychiatry. 2014;84(Issue):316-320.

KQ1 4

Altamura AC, Mundo E, Cattaneo E, et al. The MCP-1 gene (SCYA2) and mood disorders: preliminary results of 

a case-control association study. Neuroimmunomodulation. 2010;17(Issue):126-131.

KQ1 2

Anestis M. Predicting Suicide Risk in a Military Population. Military Suicide Research Consortium. 

https://msrc.fsu.edu/funded-research/predicting-suicide-risk-military-population. Accessed September 25, 2015.

KQ1 8*

Anestis MD, Khazem LR, Mohn RS, Green BA. Testing the main hypotheses of the interpersonal-psychological 

theory of suicidal behavior in a large diverse sample of United States military personnel. Compr Psychiatry. 

2015;60(Issue):78-85.

KQ1 4

Anestis MD, Silva C, Lavender JM, et al. Predicting nonsuicidal self-injury episodes over a discrete period of 

time in a sample of women diagnosed with bulimia nervosa: an analysis of self-reported trait and ecological 

momentary assessment based affective lability and previous suicide attempts. Int J Eat Disord. 

2012;45(Issue):808-811.

KQ1 6

Antypa N, Antonioli M, Serretti A. Clinical, psychological and environmental predictors of prospective suicide 

events in patients with Bipolar Disorder. J Psychiatr Res. 2013;47(Issue):1800-1808.

KQ1 4

Aomori University of Health and Welfare. A Community-based Depression Screening Intervention for Middle- KQ2 2
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

105

Citation

Key 

Question

Exclusion 

Code

aged Suicide. ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02468466. Accessed September 25,

2015.

Arana A, Wentworth CE, Ayuso-Mateos JL, Arellano FM. Suicide-related events in patients treated with 

antiepileptic drugs. N Engl J Med. 2010;363(Issue):542-551.

KQ2 4

Arbore P. A San Francisco-Based Center Reaches Out with Supportive Services for Mid-Life and Older Adults at 

Risk for Depression and Suicide. Generations. 2014;38(Issue):27-29.

KQ1 8

Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality disorders: 

short-term day hospital psychotherapy versus outpatient individual therapy - a randomized controlled study. Eur 

Psychiatry. 2009;24(Issue):71-78.

KQ2 2

Aschan L, Goodwin L, Cross S, Moran P, Hotopf M, Hatch SL. Suicidal behaviours in South East London: 

prevalence, risk factors and the role of socio-economic status. J Affect Disord. 2013;150(Issue):441-449.

KQ1 4

Assistance Publique - Hôpitaux de Paris. Randomized Controlled and Prospective Trial of a Cohort of People 

Who Made a Suicide Attempt. ClinicalTrials.gov. 2012; https://ClinicalTrials.gov/show/NCT01176929. 

Accessed September 25, 2015.

KQ2 2

Ayer DW, Jayathilake K, Meltzer HY. The InterSePT suicide scale for prediction of imminent suicidal behaviors. 

Psychiatry Res. 2008;161(Issue):87-96.

KQ1 3

Baca-Garcia E, Perez-Rodriguez MM, Oquendo MA, et al. Estimating risk for suicide attempt: are we asking the 

right questions? Passive suicidal ideation as a marker for suicidal behavior. J Affect Disord. 2011;134(Issue):327-

332.

KQ1 4

Bachynski KE, Canham-Chervak M, Black SA, Dada EO, Millikan AM, Jones BH. Mental health risk factors for 

suicides in the US Army, 2007--8. Inj Prev. 2012;18(Issue):405-412.

KQ1 4

Bagge C, Conner K. Looking for Suicide Warning Signs. Military Suicide Research Consortium. 

https://msrc.fsu.edu/funded-research/looking-suicide-warning-signs. Accessed September 25, 2015.

KQ1 8*

Bagge CL, Lamis DA, Nadorff M, Osman A. Relations between hopelessness, depressive symptoms and 

suicidality: Mediation by reasons for living. J Clin Psychol. 2014;70(Issue):18-31.

KQ1 4

Bagge CL, Littlefield AK, Rosellini AJ, Coffey SF. Relations among behavioral and questionnaire measures of 

impulsivity in a sample of suicide attempters. Suicide Life Threat Behav. 2013;43(Issue):460-467.

KQ1 4

Bakst S, Rabinowitz J, Bromet EJ. Is poor premorbid functioning a risk factor for suicide attempts in firstadmission psychosis? Schizophr Res. 2010;116(Issue):210-216.KQ1 3

Baldessarini R, Tondo L. Suicidal risks during treatment of bipolar disorder patients with lithium versus 

anticonvulsants. Pharmacopsychiatry. 2009;42(Issue):72-75.

KQ1 4

Baldessarini RJ, Tondo L. Lithium and suicidal risk. Bipolar Disorders. 2008;10(Issue):114-115. KQ1 4

Barber CR, Weinberg EF. Integrative Multidisciplinary Treatment in the public sector: A pilot study. Bull 

Menninger Clin. 2010;74(Issue):263-282.

KQ2 6

Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of suicide: A systematic review 

of observational studies. Can Med Assoc J. 2009;180(Issue):291-297.

KQ2 4

Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: Mentalizationbased treatment versus treatment as usual. Am J Psychiatry. 2008;165(Issue):631-638.KQ2 4

Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured 

clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(Issue):1355-1364.

KQ2 4

Batey H, May J, Andrade J. Negative intrusive thoughts and dissociation as risk factors for self-harm. Suicide 

Life Threat Behav. 2010;40(Issue):35-49.

KQ1 6

Baud P, Perroud N, Courtet P, et al. Modulation of anger control in suicide attempters by TPH-1. Genes Brain 

Behav. 2009;8(Issue):97-100.

KQ1 2

Beautrais AL, Gibb SJ, Faulkner A, Fergusson DM, Mulder RT. Postcard intervention for repeat self-harm: 

randomised controlled trial. Br J Psychiatry. 2010;197(Issue):55-60.

KQ2 6

Beautrais AL, Gibb SJ, Fergusson DM, Horwood LJ, Larkin GL. Removing bridge barriers stimulates suicides: 

an unfortunate natural experiment. Aust N Z J Psychiatry. 2009;43(Issue):495-497.

KQ2 4

Bebbington PE, Minot S, Cooper C, et al. Suicidal ideation, self-harm and attempted suicide: results from the 

British psychiatric morbidity survey 2000. Eur Psychiatry. 2010;25(Issue):427-431.

KQ1 4

Becker M, Brown L, Ochshorn E, Diamond R. Risk for suicide among medicaid beneficiaries. Suicide Life 

Threat Behav. 2009;39(Issue):172-181.

KQ1 4
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Citation

Key 

Question

Exclusion 

Code

Bedi S, Nelson EC, Lynskey MT, et al. Risk for suicidal thoughts and behavior after childhood sexual abuse in

women and men. Suicide Life Threat Behav. 2011;41(Issue):406-415.

KQ1 4

Beghi M, Rosenbaum JF. Risk factors for fatal and nonfatal repetition of suicide attempt: a critical appraisal. 

Curr Opin Psychiatry. 2010;23(Issue):349-355.

KQ1 4

Belnap BH, Schulberg HC, He F, Mazumdar S, Reynolds CF, III, Rollman BL. Electronic protocol for suicide 

risk management in research participants. J Psychosom Res. 2015;78(Issue):340-345.

KQ1 6

Ben-Efraim YJ, Wasserman D, Wasserman J, Sokolowski M. Family-based study of HTR2A in suicide attempts: 

observed gene, gene x environment and parent-of-origin associations. Mol Psychiatry. 2013;18(Issue):758-766.

KQ1 2

Ben-Efraim YJ, Wasserman D, Wasserman J, Sokolowski M. Family-based study of AVPR1B association and 

interaction with stressful life events on depression and anxiety in suicide attempts. Neuropsychopharmacology. 

2013;38(Issue):1504-1511.

KQ1 2

Bergen H, Hawton K, Waters K, Cooper J, Kapur N. Psychosocial assessment and repetition of self-harm: the 

significance of single and multiple repeat episode analyses. J Affect Disord. 2010;127(Issue):257-265.

KQ1 6

Bergmans Y, Links PS. Reducing potential risk factors for suicide-related behavior with a group intervention for 

clients with recurrent suicide-related behavior. Ann Clin Psychiatry. 2009;21(Issue):17-25.

KQ2 6

Berlim MT, van den Eynde F, Tovar-Perdomo S, Chachamovich E, Zangen A, Turecki G. Augmenting 

antidepressants with deep transcranial magnetic stimulation (DTMS) in treatment-resistant major depression. 

World J Biol Psychiatry. 2014;15(Issue):570-578.

KQ2 6

Bernal G. UPR RP Suicide Prevention Program. 

https://projectreporter.nih.gov/project_info_description.cfm?aid=8286671. Accessed September 25, 2015.

KQ2 8

Bernert RA, Kim JS, Iwata NG, Perlis ML. Sleep disturbances as an evidence-based suicide risk factor. Current 

Psychiatry Reports. 2015;17(Issue):554.

KQ1 4

Berrouiguet S, Alavi Z, Vaiva G, et al. SIAM (Suicide intervention assisted by messages): The development of a 

post-acute crisis text messaging outreach for suicide prevention. BMC Psychiatry. 2014;14(Issue):294.

KQ2 8

Berrouiguet S, Gravey M, Le Galudec M, Alavi Z, Walter M. Post-acute crisis text messaging outreach for 

suicide prevention: A pilot study. Psychiatry Res. 2014;217(Issue):154-157.

KQ2 2

Betz ME, Miller M, Barber C, et al. Lethal means restriction for suicide prevention: beliefs and behaviors of 

emergency department providers. Depress Anxiety. 2013;30(Issue):1013-1020.

KQ2 6

Bhaskaran J, Wang Y, Roos L, Sareen J, Skakum K, Bolton JM. Method of suicide attempt and reaction to 

survival as predictors of repeat suicide attempts: a longitudinal analysis. J Clin Psychiatry. 2014;75(Issue):e802-

808.

KQ1 4

Bhui KS, McKenzie K. Rates and risk factors by ethnic group for suicides within a year of contact with mental 

health services in England and Wales. Psychiatr Serv. 2008;59(Issue):414-420.

KQ1 4

Bilen K, Pettersson H, Owe-Larsson B, et al. Can early follow-up after deliberate self-harm reduce repetition? A 

prospective study of 325 patients. J Affect Disord. 2014;152-154(Issue):320-325.

KQ2 2

Bilen K, Ponzer S, Ottosson C, et al. Can repetition of deliberate self-harm be predicted? A prospective 

multicenter study validating clinical decision rules. J Affect Disord. 2013;149(Issue):253-258.

KQ1 2

Blasco-Fontecilla H, Delgado-Gomez D, Legido-Gil T, de Leon J, Perez-Rodriguez MM, Baca-Garcia E. Can the 

Holmes-Rahe Social Readjustment Rating Scale (SRRS) be used as a suicide risk scale? An exploratory study. 

Arch Suicide Res. 2012;16(Issue):13-28.

KQ1 2

Blasco-Fontecilla H, Delgado-Gomez D, Ruiz-Hernandez D, Aguado D, Baca-Garcia E, Lopez-Castroman J. 

Combining scales to assess suicide risk. J Psychiatr Res. 2012;46(Issue):1272-1277.

KQ1 2

Blasczyk-Schiep S, Kazen M, Kuhl J, Grygielski M. Appraisal of suicidal risk among adolescents and young 

adults through the Rorschach test. J Pers Assess. 2011;93(Issue):518-526.

KQ1 2

Blosnich JR, Brown GR, Shipherd JC, Kauth M, Piegari RI, Bossarte RM. Prevalence of gender identity disorder 

and suicide risk among transgender veterans utilizing Veterans Health Administration care. Am J Public Health. 

2013;103(Issue):e27-e32.

KQ1 4

Blum N, St John D, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) 

for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J 

Psychiatry. 2008;165(Issue):468-478.

KQ2 6

Bohnert KM, Ilgen MA, McCarthy JF, Ignacio RV, Blow FC, Katz IR. Tobacco use disorder and the risk of 

suicide mortality. Addiction. 2014;109(Issue):155-162.

KQ1 4

Bolton JM, Cox BJ, Afifi TO, Enns MW, Bienvenu OJ, Sareen J. Anxiety disorders and risk for suicide attempts: KQ1 4
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Citation

Key 

Question

Exclusion 

Code

findings from the Baltimore Epidemiologic Catchment area follow-up study. Depress Anxiety. 

2008;25(Issue):477-481.

Bolton JM, Pagura J, Enns MW, Grant B, Sareen J. A population-based longitudinal study of risk factors for 

suicide attempts in major depressive disorder. J Psychiatr Res. 2010;44(Issue):817-826.

KQ1 4

Bongiovi-Garcia ME, Merville J, Almeida MG, et al. Comparison of clinical and research assessments of 

diagnosis, suicide attempt history and suicidal ideation in major depression. J Affect Disord. 

2009;115(Issue):183-188.

KQ1 6

Booth R, Keogh K, Doyle J, Owens T. Living through distress: A skills training group for reducing deliberate 

self-harm. Behav Cogn Psychother. 2014;42(Issue):156-165.

KQ2 6

Borges G, Angst J, Nock MK, Ruscio AM, Kessler RC. Risk factors for the incidence and persistence of suiciderelated outcomes: a 10-year follow-up study using the National Comorbidity Surveys. J Affect Disord. 

2008;105(Issue):25-33.

KQ1 4

Boyce N. Pilots of the future: Suicide prevention and the internet. The Lancet. 2010;376(Issue):1889-1890. KQ2 8

Bradvik L, Mattisson C, Bogren M, Nettelbladt P. Long-term suicide risk of depression in the Lundby cohort 

1947-1997--severity and gender. Acta Psychiatr Scand. 2008;117(Issue):185-191.

KQ1 2

Braithwaite E, Charette Y, Crocker AG, Reyes A. The predictive validity of clinical ratings of the Short-Term 

Assessment of Risk and Treatability (START). Int J Forensic Ment Health. 2010;9(Issue):271-281.

KQ1 4

Brechlin T, Myers K. 0077 Good from tragedy? enhancing prevention, intervention and postvention of suicide

through the comprehensive, multidisciplinary reviews of suicide deaths in utah. Inj Prev. 2015;21(Issue):A19.

KQ2 8

Brenner L, Military Suicide Research Consortium, VA Eastern Colorado Health Care System. Window to HopeEvaluating a Psychological Treatment for Hopelessness Among Veterans With Traumatic Brain Injury (WtoH). 

ClinicalTrials.gov. 2014; https://ClinicalTrials.gov/show/NCT01691378. Accessed September 25, 2015.

KQ2 8

Brenner L, Simpson G, Forster J, et al. Window to hope: Preliminary results from a randomized controlled trial 

(RCT) of a psychological treatment for hopelessness among US veterans with traumatic brain injury (TBI). Brain 

Inj. 2014;28(Issue):737.

KQ2 6

Britton PC, Bossarte RM, Thompson C, Kemp J, Conner KR. Influences on call outcomes among veteran callers 

to the National Veterans Crisis Line. Suicide Life Threat Behav. 2013;43(Issue):494-502.

KQ2 6

Britton PC, Ilgen MA, Rudd MD, Conner KR. Warning signs for suicide within a week of healthcare contact in 

Veteran decedents. Psychiatry Res. 2012;200(Issue):395-399.

KQ1 4

Britton PC, Ilgen MA, Valenstein M, Knox K, Claassen CA, Conner KR. Differences between veteran suicides 

with and without psychiatric symptoms. Am J Public Health. 2012;102 Suppl 1(Issue):S125-130.

KQ1 4

Bronx Veterans Medical Research Foundation. High Risk Suicidal Behavior in Veterans. ClinicalTrials.gov. 

2015; https://ClinicalTrials.gov/show/NCT02462694. Accessed September 25, 2015.

KQ2 8†

Brooke Army Medical Center. Ketamine for Acute Suicidal Ideation in the Emergency Department: Randomized 

Controlled Trial. ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01892995. Accessed September 

25, 2015.

KQ2 8

Brown GK, Green KL. A review of evidence-based follow-up care for suicide prevention: where do we go from 

here? Am J Prev Med. 2014;47(Issue):S209-215.

KQ2 8

Brown MZ, Linehan MM, Comtois KA, Murray A, Chapman AL. Shame as a prospective predictor of selfinflicted injury in borderline personality disorder: a multi-modal analysis. Behav Res Ther. 2009;47(Issue):815-

822.

KQ1 4

Brown S, Langrish M. Evaluation of a risk assessment tool to predict violent behaviour by patients detained in a 

psychiatric intensive care unit. Journal of Psychiatric Intensive Care. 2012;8(Issue):35-41.

KQ1 6

Brundin L, Bjorkqvist M, Traskman-Bendz L, Petersen A. Increased orexin levels in the cerebrospinal fluid the 

first year after a suicide attempt. J Affect Disord. 2009;113(Issue):179-182.

KQ1 2

Bryan CJ, Bryan AO, Ray-Sannerud BN, Etienne N, Morrow CE. Suicide attempts before joining the military 

increase risk for suicide attempts and severity of suicidal ideation among military personnel and veterans. Compr 

Psychiatry. 2014;55(Issue):534-541.

KQ1 4

Bryan CJ, Clemans TA. Repetitive traumatic brain injury, psychological symptoms, and suicide risk in a clinical 

sample of deployed military personnel. JAMA Psychiatry. 2013;70(Issue):686-691.

KQ1 4

Bryan CJ, Cukrowicz KC. Associations between types of combat violence and the acquired capability for suicide. 

Suicide Life Threat Behav. 2011;41(Issue):126-136.

KQ1 6

Bryan CJ, David Rudd M, Wertenberger E, et al. Improving the detection and prediction of suicidal behavior KQ1 4
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Citation

Key 

Question

Exclusion 

Code

among military personnel by measuring suicidal beliefs: an evaluation of the Suicide Cognitions Scale. J Affect 

Disord. 2014;159(Issue):15-22.

Bryan CJ, Dhillon-Davis LE, Dhillon-Davis KK. Emotional impact of a video-based suicide prevention program 

on suicidal viewers and suicide survivors. Suicide Life Threat Behav. 2009;39(Issue):623-632.

KQ2 6

Bryan CJ, Gonzales J, Rudd DM, et al. Depression Mediates the Relation of Insomnia Severity with Suicide Risk 

in Three Clinical Samples of U.S. Military Personnel. Depress Anxiety. 2015(Issue).

KQ1 4

Bryan CJ, Griffith JH, Pace BT, et al. Combat exposure and risk for suicidal thoughts and behaviors among 

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Lyddon R, Dwork AJ, Keddache M, Siever LJ, Dracheva S. Serotonin 2c receptor RNA editing in major 

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Lynch SM, Forman E, Mendelsohn M, Herman J. Attending to Dissociation: Assessing Change in Dissociation 

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Malloy-Diniz LF, Neves FS, Abrantes SS, Fuentes D, Correa H. Suicide behavior and neuropsychological 

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Massachusetts General Hospital, American Foundation for Suicide Prevention. Intranasal Ketamine for Late-Life 

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Massachusetts General Hospital, American Foundation for Suicide Prevention. Trial of a Positive Psychology 

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Massachusetts General Hospital, American Foundation for Suicide Prevention. Brief Sleep Intervention for 

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Michigan Uo, Abuse NIoD. Developing an Intervention to Address Suicide Risk During Substance Use Disorder. 

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New SAMHSA Study on Link Between Suicide and Substance Abuse. Policy & Practice (19426828). 

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Pfeiffer PN, Ganoczy D, Ilgen M, Zivin K, Valenstein M. Comorbid anxiety as a suicide risk factor among 

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Pfeiffer PN, Kim HM, Ganoczy D, Zivin K, Valenstein M. Treatment-resistant depression and risk of suicide. 

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Pigeon WR, Caine ED. Insomnia and the risk for suicide: Does sleep medicine have interventions that can make a 

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Pintor L, Torres X, Navarro V, Martinez de Osaba MA, Matrai S, Gasto C. Prediction of relapse in melancholic 

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Plakun EM. A view from Riggs: treatment resistance and patient authority-XI. An alliance based intervention for 

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Pompili M, Innamorati M, Mann JJ, et al. Periventricular white matter hyperintensities as predictors of suicide 

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Pompili M, Lester D, Innamorati M, et al. Suicide risk and exposure to mobbing. Work. 2008;31(Issue):237-243. KQ1 2

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KQ2 3

University of Massachusetts at Worcester, National Institute of Mental Health. Emergency Department Safety 

Assessment and Follow-up Evaluation 2 (ED-SAFE-2). ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT02453243. Accessed September 25, 2015.

KQ2 8

University of Massachusetts W, National Institute of Mental H. Emergency Department Safety Assessment and 

Follow-up Evaluation (ED-SAFE). ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01150994. 

Accessed September 25, 2015.

KQ1 & 

KQ2

8

University of Michigan, National Institutes of Health, Pfeiffer P. Peer Mentorship to Reduce Suicide Risk 

Following Psychiatric Hospitalization (PREVAIL Study). ClinicalTrials.gov. 2015; NCT02365116. 

https://ClinicalTrials.gov/show/NCT02365116. Accessed September 25, 2015.

KQ2 8

University of Michigan, U. S. Army Medical Research and Materiel Command, Department of Defense, 

Department of Veterans Affairs. Intervening to Reduce Suicide Risk in Veterans With Substance Use Disorders. 

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02439762. Accessed September 25, 2015.

KQ2 8†

University of Nevada at Reno, The Catholic University of America, National Institute of Mental Health. 

Developing Adaptive Interventions for Suicidal College Students Seeking Treatment - SMART. 

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02442869. Accessed September 25, 2015.

KQ2 8

University of Pennsylvania, National Institute of Mental Health, Beck AT, Brown GK. Cognitive Therapy for 

Suicidal Older Men in Primary Care Settings. ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT00149773. Accessed September 25, 2015.

KQ2 8

University of Pennsylvania, National Institute of Mental Health. Cognitive Therapy for Suicidal Older Men. 

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01535482. Accessed September 25, 2015.

KQ2 8

University of Rochester, National Institute of Mental Health. Social Connections and Late Life Suicide. 

ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02188485. Accessed September 25, 2015.

KQ2 8

University of Utah, The University of Texas Health Science Center at San Antonio. Brief Interventions for ShortTerm Suicide Risk Reduction in Military Populations. ClinicalTrials.gov. 2015; 

https://ClinicalTrials.gov/show/NCT02042131. Accessed September 25, 2015.

KQ2 8†

University of Washington, Military Suicide Research Consortium, Department of Veterans Affairs, Department 

of Defense. Military Continuity Project. ClinicalTrials.gov. 2013; https://ClinicalTrials.gov/show/NCT01829620. 

Accessed September 25, 2015.

KQ2 8†

University of Washington, National Institute of Mental Health. Treating PTSD in Patients With Borderline 

Personality Disorder. ClinicalTrials.gov. 2013; https://ClinicalTrials.gov/show/NCT01081314. Accessed

September 25, 2015.

KQ2 8

University of Washington. A Policy Relevant US Trauma Care System Pragmatic Trial for PTSD and 

Comorbidity Pilot. ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02335125. Accessed September 

25, 2015.

KQ2 4

University of Washington. Brief Skills Training Intervention for Suicidal Individuals. ClinicalTrials.gov. 2014; KQ2 8
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Code

https://ClinicalTrials.gov/show/NCT02236325. Accessed September 25, 2015.

University of Washington. Improving Care Provided to Patients Treated in a Level 1 Trauma Center Post-suicide 

Attempt. ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01355848. Accessed September 25, 2015.

KQ2 8

VA Connecticut Healthcare System, Department of Veterans Affairs. Dialectical Behavior Therapy Skills Group 

Pilot Evaluation. ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT02499406. Accessed September 

25, 2015.

KQ2 8

VA Eastern Colorado Health Care System, Department of Defense, Gutierrez P. Blister Packaging Medication to 

Increase Treatment Adherence and Clinical Response. ClinicalTrials.gov. 2015; NCT01118208. 

https://ClinicalTrials.gov/show/NCT01118208. Accessed September 25, 2015.

KQ2 8†

VA Eastern Colorado Health Care System, Department of Veterans Affairs, Department of Defense, Columbia 

University, University of Pennsylvania, Uniformed Services University of the Health Sciences. A Brief 

Intervention to Reduce Suicide Risk in Military Service Members and Veterans- Study 1. ClinicalTrials.gov. 

2014; https://ClinicalTrials.gov/show/NCT01334541. Accessed September 25, 2015.

KQ2 8†

VA Eastern Colorado Health Care System, University of Colorado at Denver, Portland State University, 

University of Missouri at Kansas City. Operation Enduring Freedom/Operation Iraqi Freedom Veterans' 

Experiences of Habituation to Pain, Perceived Burdensomeness, and Failed Belongingness. ClinicalTrials.gov. 

2011; https://ClinicalTrials.gov/show/NCT01334385. Accessed September 25, 2015.

KQ1 4

VA Eastern Colorado Health Care System, University of Colorado at Denver. Prolonged Grief and Suicide 

Among Veterans. ClinicalTrials.gov. 2014; https://ClinicalTrials.gov/show/NCT01247025. Accessed September 

25, 2015.

KQ1 4

VA Eastern Colorado Health Care System. An Exploration of the Relationship Between Chronic Pain and 

Suicide Attempt Among Veterans. ClinicalTrials.gov. 2012; https://ClinicalTrials.gov/show/NCT01502436. 

Accessed September 25, 2015.

KQ1 4

VA Eastern Colorado Health Care System. Experiential Avoidance in Combat Veterans With and Without 

Posttraumatic Stress Disorder. ClinicalTrials.gov. 2015; https://ClinicalTrials.gov/show/NCT01652430. 

Accessed September 25, 2015.

KQ1 4

VA Eastern Colorado Health Care System. Personal Values, Interpersonal Needs, and Suicidal Ideation in a 

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September 25, 2015.

KQ1 4

Vaiva G, Vaiva G, Ducrocq F, et al. Effect of telephone contact on further suicide attempts in patients discharged 

from an emergency department: randomised controlled study. BMJ. 2006;332(Issue):1241-1245.

KQ2 2

Valenstein M, Eisenberg D, McCarthy JF, et al. Service implications of providing intensive monitoring during 

high-risk periods for suicide among VA patients with depression. Psychiatr Serv. 2009;60(Issue):439-444.

KQ2 6

Valuck RJ, Orton HD, Libby AM. Antidepressant discontinuation and risk of suicide attempt: a retrospective, 

nested case-control study. J Clin Psychiatry. 2009;70(Issue):1069-1077.

KQ1 4

van Beek W, Kerkhof A, Beekman A. Future oriented group training for suicidal patients: a randomized clinical 

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KQ2 2

van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, et al. Best practice elements of multilevel suicide 

prevention strategies: a review of systematic reviews. Crisis. 2011;32(Issue):319-333.

KQ2 9

van Spijker BAJ, Calear AL, Batterham PJ, et al. Reducing suicidal thoughts in the Australian general population 

through web-based self-help: Study protocol for a randomized controlled trial. Trials. 2015;16(Issue).

KQ2 8

Vang FJ, Lindstrom M, Sunnqvist C, Bah-Rosman J, Johanson A, Traskman-Bendz L. Life-time adversities, 

reported thirteen years after a suicide attempt: relationship to recovery, 5HTTLPR genotype, and past and present 

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KQ1 2

Vriniotis M, Barber C, Frank E, Demicco R. A suicide prevention campaign for firearm dealers in new 

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KQ2 6

Wachtel S, Vocks S, Edel MA, Nyhuis P, Willutzki U, Teismann T. Validation and psychometric properties of 

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KQ1 2

Waern M, Sjostrom N, Marlow T, Hetta J. Does the Suicide Assessment Scale predict risk of repetition? A 

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KQ1 2

Wagner G, Koch K, Schachtzabel C, Schultz CC, Sauer H, Schlosser RG. Structural brain alterations in patients 

with major depressive disorder and high risk for suicide: evidence for a distinct neurobiological entity? 

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KQ1 2
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Wagner G, Schultz CC, Koch K, Schachtzabel C, Sauer H, Schlosser RG. Prefrontal cortical thickness in 

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KQ1 2

Wang L-J, Wu Y-W, Chen C-K. Is case management effective for long-lasting suicide prevention? A community 

cohort study in Northern Taiwan. Crisis. 2015;36(Issue):194-201.

KQ2 2

Ward-Ciesielski EF. An open pilot feasibility study of a brief dialectical behavior therapy skills-based 

intervention for suicidal individuals. Suicide Life Threat Behav. 2013;43(Issue):324-335.

KQ2 6

Wasserman D, Sokolowski M, Rozanov V, Wasserman J. The CRHR1 gene: a marker for suicidality in depressed 

males exposed to low stress. Genes Brain Behav. 2008;7(Issue):14-19.

KQ1 2

Wasserman D, Terenius L, Wasserman J, Sokolowski M. The 2009 Nobel conference on the role of genetics in 

promoting suicide prevention and the mental health of the population. Mol Psychiatry. 2010;15(Issue):12-17.

KQ2 8

Wells TS, Horton JL, LeardMann CA, Jacobson IG, Boyko EJ. A comparison of the PRIME-MD PHQ-9 and 

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KQ1 4

Western Kentucky University, Vanderbilt University. Pilot Study of a Brief Intervention for Medically 

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KQ2 8

White R, Barber C, Azrael D, Mukamal KJ, Miller M. History of military service and the risk of suicidal 

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KQ1 4

Williams AD, Andrews G. The effectiveness of internet cognitive behavioural therapy (iCBT) for depression in 

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KQ2 6

Willour VL, Seifuddin F, Mahon PB, et al. A genome-wide association study of attempted suicide. Mol 

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KQ1 4

Winter D, Bradshaw S, Bunn F, Wellsted D. A systematic review of the literature on counselling and 

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KQ2 6

Winter D, Bradshaw S, Bunn F, Wellsted D. A systematic review of the literature on counselling and 

psychotherapy for the prevention of suicide: 1. Quantitative outcome and process studies. Counselling and 

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KQ2 9

Witte TK, Gould MS, Munfakh JL, Kleinman M, Joiner TE, Jr., Kalafat J. Assessing suicide risk among callers 

to crisis hotlines: a confirmatory factor analysis. J Clin Psychol. 2010;66(Issue):941-964.

KQ1 4

Witte TK, Timmons KA, Fink E, Smith AR, Joiner TE. Do major depressive disorder and dysthymic disorder 

confer differential risk for suicide? J Affect Disord. 2009;115(Issue):69-78.

KQ1 4

Wolk CB, Kendall PC, Beidas RS. Cognitive-behavioral therapy for child anxiety confers long-term protection 

from suicidality. J Am Acad Child Adolesc Psychiatry. 2015;54(Issue):175-179.

KQ2 4

Woodhead C, Rona RJ, Iversen A, et al. Mental health and health service use among post-national service 

veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England. Psychol Med. 

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KQ1 4

Woolley SB, Fredman L, Goethe JW, Lincoln AK, Heeren T. Headache complaints and the risk of suicidal 

thoughts or behaviors. J Nerv Ment Dis. 2008;196(Issue):822-828.

KQ1 4

Wray M, Gurvey J, Miller M, Kawachi I. Estimating visitor suicide risk in destination cities: A reply to 

Zarkowski and Nguyen. Soc Sci Med. 2012;74(Issue):1474-1476.

KQ1 4

Wray M, Miller M, Gurvey J, Carroll J, Kawachi I. Leaving Las Vegas: Exposure to Las Vegas and risk of 

suicide. Soc Sci Med. 2008;67(Issue):1882-1888.

KQ1 4

Wright KM, Adler AB, Bliese PD, Eckford RD. Structured clinical interview guide for postdeployment 

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KQ1 6

Wyder M, Ward P, De Leo D. Separation as a suicide risk factor. J Affect Disord. 2009;116(Issue):208-213. KQ1 4

Yaldizli O, Kuhl HC, Graf M, Wiesbeck GA, Wurst FM. Risk factors for suicide attempts in patients with alcohol 

dependence or abuse and a history of depressive symptoms: a subgroup analysis from the WHO/ISBRA study. 

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KQ1 2

Yaseen Z, Katz C, Johnson MS, Eisenberg D, Cohen LJ, Galynker, II. Construct development: The Suicide 

Trigger Scale (STS-2), a measure of a hypothesized suicide trigger state. BMC Psychiatry. 2010;10(Issue):110.

KQ1 6

Yen CF, Chen CS, Yen JY, Ko CH. The predictive effect of insight on adverse clinical outcomes in bipolar I KQ1 2
Systematic Review of Suicide Prevention in Veterans Evidence-based Synthesis Program

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Exclusion 

Code

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Yen CF, Lee Y, Tang TC, Yen JY, Ko CH, Chen CC. Predictive value of self-stigma, insight, and perceived 

adverse effects of medication for the clinical outcomes in patients with depressive disorders. J Nerv Ment Dis. 

2009;197(Issue):172-177.

KQ1 2

Yen S, Shea MT, Sanislow CA, et al. Personality traits as prospective predictors of suicide attempts. Acta 

Psychiatr Scand. 2009;120(Issue):222-229.

KQ1 7

Yip P, Pitt D, Wang Y, et al. Assessing the impact of suicide exclusion periods on life insurance. Crisis. 

2010;31(Issue):217-223.

KQ1 4

York J, Lamis DA, Friedman L, et al. A Systematic Review Process to Evaluate Suicide Prevention Programs: A 

Sample Case of Community-Based Programs. J Community Psychol. 2013;41(Issue):35-51.

KQ2 3

York JA, Lamis DA, Pope CA, Egede LE. Veteran-specific suicide prevention. Psychiatr Q. 2013;84(Issue):219-

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KQ2 8

Yurgelun-Todd D. Using Brain Imaging to Study Suicide Risk. Military Suicide Research Consortium. 

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KQ1 4

Yur'yev A, Värnik A, Värnik P, Sisask M, Leppik L. Role of social welfare in European suicide prevention. Int J 

Soc Welfare. 2012;21(Issue):26-33.

KQ2 2

Zai CC, Manchia M, De Luca V, et al. The brain-derived neurotrophic factor gene in suicidal behaviour: a metaanalysis. Int J Neuropsychopharmacol. 2012;15(Issue):1037-1042.KQ1 4

Zalsman G, Huang YY, Oquendo MA, et al. No association of COMT Val158Met polymorphism with suicidal 

behavior or CSF monoamine metabolites in mood disorders. Arch Suicide Res. 2008;12(Issue):327-335.

KQ1 4

Zhang J, Lu J, Zhao S, et al. Developing the Psychological Strain Scales (PSS): Reliability, Validity, and 

Preliminary Hypothesis Tests. Soc Indic Res. 2014;115(Issue):337-361.

KQ1 2

Zhang L, Su TP, Choi K, et al. P11 (S100A10) as a potential biomarker of psychiatric patients at risk of suicide. J 

Psychiatr Res. 2011;45(Issue):435-441.

KQ1 2

Zhang Y, Zhang C, Yuan G, et al. Effect of tryptophan hydroxylase-2 rs7305115 SNP on suicide attempts risk in 

major depression. Behav Brain Funct. 2010;6(Issue):49.

KQ1 2

Zisook S, Lesser IM, Lebowitz B, et al. Effect of antidepressant medication treatment on suicidal ideation and 

behavior in a randomized trial: An exploratory report form the combining medications to enhance depression 

outcomes study. J Clin Psychiatry. 2011;72(Issue):1322-1332.

KQ2 4

* Not included as a study in the systematic review because study results are not yet available, but listed in the table of Ongoing 

Studies of Methods to Identify Suicide Risk (Table 10).

† Not included as a study in the systematic review because study results are not yet available, but listed in the table of Ongoing 

Studies of Healthcare Service Interventions for Suicide Prevention (Table 11).