Suicide Risk Evaluations and Suicide in the Veterans Health Administration
Authors: Kevin G. Saulnier, Courtney L. Bagge, Dara Ganoczy, Nazanin H. Bahraini, Jennifer Jagusch, Avinash Hosanagar, Mark A. Ilgen, Paul N. Pfeiffer
Journal: JAMA Network Open (2025)

Importance The Veterans Health Administration (VHA) implemented the Comprehensive Suicide Risk Evaluation (CSRE) in 2019 to standardize suicide risk assessment across the health care system. Identifying CSRE responses associated with suicide could inform risk management and prevent suicide. Objective To identify CSRE responses associated with subsequent suicide. Design, Setting, and Participants This cohort study examines acute (within 30 days) and chronic (within 365 days) suicide risk after 269 374 CSREs were administered. Participants included US VHA patients undergoing CSRE evaluation between November 1, 2019, and December 31, 2020. Data collection and analysis were performed from April 5 to August 20, 2024. Exposures CSRE responses, including suicidal ideation, behaviors, warning signs, risk factors, and protective factors. Main Outcome and Measure Suicide per death certificate data from the Department of Veterans Affairs and Department of Defense Mortality Data Repository. Outcomes were analyzed using multivariable Cox proportional hazards regression. Results A total of 153 736 patients with 269 374 valid CSREs (86.26% male; mean [SD] age, 50.48 [15.26] years) were included in the multivariable-adjusted analyses of suicide. Suicidal ideation (hazard ratio [HR], 3.14; 95% CI, 1.51-6.54), firearm access (HR, 2.62; 95% CI, 1.49-4.61), making preparations for a suicide attempt (HR, 2.15; 95% CI, 1.27-3.62), seeking access to lethal means (HR, 2.04; 95% CI, 1.11-3.75), anxiety (HR, 1.80; 95% CI, 1.16-2.81), and psychiatric hospitalization history (HR, 1.63; 95% CI, 1.02-2.61) were associated with increased suicide risk within 30 days, whereas anger (HR, 0.50; 95% CI, 0.30-0.85) was associated with decreased risk. Suicidal ideation (HR, 1.63; 95% CI, 1.20-2.21), firearm access (HR, 1.55; 95% CI, 1.13-2.13), making preparations for a suicide attempt (HR, 1.56; 95% CI, 1.09-2.23), reckless behaviors (HR, 1.40; 95% CI, 1.00-1.95), and history of psychiatric hospitalization (HR, 1.68; 95% CI, 1.32-2.13) were associated with increased suicide risk within 365 days, whereas anger (HR, 0.56; 95% CI, 0.44-0.71), preexisting risk factors (eg, trauma; HR, 0.77; 95% CI, 0.62-0.96), and recent transition from the military (HR, 0.39; 95% CI, 0.22-0.70) were associated with decreased risk in multivariable-adjusted analyses. Suicide risk within 365 days was elevated among patients identified by clinicians to be at intermediate acute risk (HR, 1.39; 95% CI, 1.13-1.71), intermediate chronic risk (HR, 1.34; 95% CI, 1.01-1.77), and high chronic risk (HR, 1.74; 95% CI, 1.22-2.47) of suicide compared with patients at low risk in multivariable-adjusted analyses. Conclusions and Relevance In this cohort study of suicide following risk assessments, findings suggest that only a few constructs are associated with subsequent suicide, particularly suicidal ideation, firearm access, and preparatory behaviors. Developing risk prediction algorithms including CSRE responses may enhance clinical evaluation.