Recent research published in journals psychiatric services Our findings suggest that simple suicide prevention programs are being successfully implemented for at-risk veterans across the Veterans Health Administration. This study provides evidence that patients at high risk for suicide are more likely to complete these safety plans, especially if hospital policy requires them. These findings provide insights that can help health systems improve suicide prevention strategies and ensure more equitable care for all patients.
Suicide rates in the United States have increased by approximately 30% over the past 20 years. This growing public health crisis has led medical professionals to seek effective ways to help people in moments of acute mental distress. Accumulating evidence suggests that short-term behavioral interventions can reduce suicidal behavior and save lives. One specific approach is the Safety Planning Intervention, abbreviated as SPI.
The safety planning intervention is a structured process consisting of six different steps. Healthcare providers and patients work together to identify warning signs in individuals who may be in the midst of a crisis. It also outlines internal coping strategies, social contacts who can provide support, and ways to make the patient’s physical environment safer. This creates a personalized document that patients can easily refer to before and during a serious mental health crisis.
Gabriela Kazanov, assistant professor and director of the Treatment Access and Engagement Laboratory at Yeshiva University, wanted to evaluate how the program was being used. “The Veterans Administration has made significant investments in suicide prevention, launching a national effort in 2008 to implement Safety Planning Interventions (SPI),” Kazanov said. “SPI is a six-step brief intervention in which health care providers and patients work together to collaboratively identify coping and safety strategies to use before and during a suicidal crisis.”
Until this study, scientists had not fully analyzed the program’s national rollout. “There are no studies yet that describe this implementation effort or how it varies by clinical setting or patient characteristics,” Kazanov noted. “This information is important not only to the Veterans Administration, but also to other health systems interested in the equitable implementation of suicide prevention interventions.”
To investigate these questions, researchers examined the country’s electronic health records from December 2021 to February 2023. They focused on patients who were screened for suicide risk using a standard questionnaire called the Columbia Suicide Severity Rating Scale Screener. This simple screening tool helps health care providers determine whether a patient has considered or planned a suicide attempt in the past month.
Using this screening tool, the authors identified a large sample of 86,913 veterans who had recently experienced suicidal thoughts or behavior. This particular group of veterans was classified by the health care system as being at moderate risk for suicide. The scientists then tracked how many of these patients completed an initial safety plan within 30 days of their positive screen. It also checked whether patients simply revisited old plans they had created with their doctors in the past.
The authors found that 44.2 percent of at-risk veterans completed a brand new safety plan within 30 days of testing. An additional 7.2% reviewed their previously developed plan with their physician and determined that no changes were necessary. Some patients had already completed their plans earlier this year, while others were offered the intervention but declined to take part. Combining all of these different categories, the data showed that 69.4 percent of veterans were formally offered intervention.
The data showed high levels of engagement in large-scale programs. “VA has been remarkably effective in implementing SPI, with 69% of veterans with recent suicidal thoughts or behavior being offered intervention, and nearly all those required by VA policy to complete SPI (part of a large population at high risk for suicide) completed SPI within the required time frame (98% of eligible veterans),” Kazanov told SciPost.
Implementation of the intervention also matched the clinical needs of the patients. “Patients at high risk for suicide were more likely to complete the SPI, indicating widespread clinical adoption of this intervention,” Kazanov explained.
Certain high-risk groups, such as people being discharged from the emergency department, are strictly required by policy to complete a safety plan. The high success rate in these particular patients stood out to the research team. “We were surprised to find that 98% of veterans required by VA policy to complete the SPI completed it within the required time frame, which is a near-perfect record,” Kazanov noted.
Most of these safety plans were completed in mental health outpatient clinics or specialized inpatient facilities. Only a small proportion of the interventions took place in general clinic or acute care settings. This provides evidence that mental health professionals are primarily taking the lead in implementing this particular intervention within large hospital networks.
The scientists also looked at demographic differences among patients to identify potential disparities in care. “We also generally did not find systematic disparities in the administration of SPI for minority veterans, suggesting that mandatory screening for suicide risk in veterans has the potential to improve the equitable implementation of interventions to prevent suicide,” said Khazanov. “The message of this paper is that if health systems pay attention to suicide prevention and implement interventions thoughtfully, these efforts can be successful.”
The researchers found that patients who were younger, black, female, Hispanic or Latino, and living in urban areas were slightly more likely to complete the intervention, but the differences were not large. Mr. Kazanov provided background on these findings to avoid any misunderstandings. “Most of the numbers in this paper represent the percentage of veterans who complete SPI,” she says. “It is important to note that the sociodemographic differences we identified were small and likely only significant due to the large sample size (given the use of electronic health records).”
Identifying patients in need of assistance relies heavily on screening tools, which can pose challenges. “We evaluated SPI implementation based on patients’ self-reported suicidal ideation, but we know that many patients are hesitant to report having suicidal ideation,” Kazanov noted. “Therefore, it is important to support efforts to determine which patients are most in need of suicide prevention interventions based on characteristics, not just self-report.”
Although this study provides detailed insight into suicide prevention efforts, the authors note several limitations. “Importantly, because we only examined SPI implementation at the VA and not its quality or effectiveness, we do not know whether SPI was adequately administered or whether the implementation efforts described actually reduced suicide rates,” Kazanov explained.
Just because a safety plan is completed on a computer system, it should not be assumed that it is automatically perfect. “We only looked at SPI completion rates, not the quality of the safety plan (i.e., did clinicians do an adequate job implementing the SPI) or the effectiveness of the SPI/impact on clinical outcomes (i.e., did implementation of the SPI lead to fewer suicides or improved other outcomes),” Kazanov said. “We concluded that SPI implementation is not always of high quality or impactful, and that at-risk veterans are consistently and adequately provided with SPI.”
Future studies should examine how these safety plans affect long-term survival. “I would love to see and participate in efforts to measure the impact of SPI administration on suicide rates and other clinical outcomes,” Kazanov said.
Extending the real-world benefits will guide other hospitals in the future. “While previous studies have shown that SPI combined with telephone follow-up led to reductions in suicidal behavior in veterans treated at five VA emergency departments, examining the impact of routinely implemented SPI is critical for other health systems to determine whether and how to implement SPI in patients at risk for suicide,” said Khazanov.
The study, “National Implementation of Suicide Safety Plans in the Veterans Health Administration,” was authored by Gabriela Kattan Kazanoff, Tom Siduff, Matthew Wilson, Christopher B. Roberts, Kathryn Barry, James R. McKay, Shari Yeager-Hyman, Marianne Goodman, and Joseph A. Simonetti.
