Abstract
Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.
▪An innovative project (SAFE VET) designed to help suicidal veterans in emergency departments in the Department of Veterans Affairs (VA) has been successfully implemented in 5 intervention sites.
▪Using quality assurance data acceptability of the SAFE VET intervention was determined as percent of veterans willing to receive the intervention; information on follow-up mental health and other psychiatric services was also obtained.
▪SAFE VET is a promising alternative and acceptable delivery of care system that augments the treatment of suicidal veterans in VA emergency departments and helps ensure that they have appropriate follow-up care. If future research finds that this brief behavioral intervention is effective on key outcomes such as suicide attempts and engagement in care, the approach may be transferable to a wide variety of VA and non-VA settings, including community emergency departments and urgent care centers.
Reducing deaths from veteran suicide and decreasing the burden on individuals and families caused by suicidal behavior in veterans is an important priority for the Department of Veterans Affairs (VA). Emergency departments (EDs) frequently function as the primary or sole point of contact with the health care system for suicidal individuals.1,2 This contact often occurs either immediately following a suicide attempt or when suicidal thoughts escalate and the individual feels in danger of acting on these thoughts. Moreover, the risk of suicide is very high following contact with acute psychiatric services,3 and persistent challenges exist for providing continuity of care after discharge.4,5 Therefore, EDs represent an important venue in which to identify and treat veterans who are at risk for suicide.
In response to a priority recommendation from a Blue Ribbon Panel on Veteran Suicide in 20086 VA leadership called for development and implementation of an ED-based intervention for suicidal veterans. The rationale for such an approach was based on the recognition that ED providers may prefer to hospitalize moderate risk patients because of limited availability and feasibility of interventions that can be provided in the ED. The Blue Ribbon panel recommended that the VA address this gap in services. We describe the design and implementation of an innovative brief behavioral intervention for suicidal veterans who seek care in VA hospital EDs. The overall vision of this VA initiative was to augment emergency mental health service delivery to (1) enhance identification of veterans at risk for suicide in VA hospital EDs, (2) provide a brief intervention to reduce risk, and (3) ensure that veterans receive appropriate and timely follow-up care. This clinical demonstration project became the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment (SAFE VET) Project. Designed to mitigate suicidal thoughts and behaviors in veterans through a veteran-focused, clinical safety plan intervention conducted in EDs or Mental Health Urgent Care settings, SAFE VET includes an outreach protocol following discharge. The protocol includes facilitating the veteran’s transition to outpatient mental health care, maintaining veteran safety during this transition through regular telephone contact and reviewing and revising the veteran’s safety plan.
Prior to development of the SAFE VET project, Stanley and Brown7 developed an innovative clinical approach to suicide risk reduction across clinical settings for the general population. Stanley and Brown’s7 initial strategy consisted of a brief behavioral intervention they called Safety Planning. Following the Blue Ribbon Panel recommendation, and in collaboration with VA clinicians, Stanley and Brown8 then developed a modification of Safety Planning specifically tailored for the veteran population. The SAFE VET intervention is grounded on the tenets of Safety Planning, incorporating elements of 4 evidence-based suicide risk reduction strategies: (1) means restriction, (2) teaching brief problem-solving and coping skills (including distraction), (3) enhancing social support and identifying emergency contacts, and (4) motivational enhancement for further treatment. As a novel addition to Safety Planning, SAFE VET integrates intensive follow-up of veterans after discharge from the ED. Key to the delivery of the SAFE VET intervention was the creation of a new position in the VA, the acute services coordinator (ASC) who administers the veteran version of Safety Planning in the ED and makes all the follow-up contacts. The follow-up protocol involves both veterans and their families in implementation of the veteran’s individualized safety plan, which is tailored to the veteran’s distinctive warning signs, internal coping strategies, contacts of family members or friends, and contacts of professionals or agencies who can offer crisis assistance, including VA’s Suicide Hotline (now known as the VA’s Crisis Line).
SAFE VET primarily targets those veterans who are assessed as being at moderate risk for suicide and who often become hospitalized. SAFE VET allows for immediate reduction in distress and therefore can provide an alternative to hospitalization. However, identification of high risk veterans also is a critical component of the SAFE VET Project because veterans identified as high risk may be hospitalized, placed on a VA Suicide Prevention Coordinator’s high-risk list, or referred for comprehensive outpatient follow-up. Regardless of level of risk, all veterans in the SAFE VET intervention receive VA’s Crisis Line number. Figure 1 outlines the pathway of veterans seen in VA ED or Urgent Care who are determined to be at some level of risk for suicidal behaviors.
FIGURE 1— Pathways to care for veterans in Veterans Affairs (VA) emergency department (ED) or urgent care settings.
Note. SAFE VET = Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment.
FIGURE 2— Logo used to promote SAFE VET program.
Because SAFE VET is a practical translation of science to service, VA leadership designated an executive committee to develop and oversee the project infrastructure, as well as to disseminate findings of the project. This committee is responsible for quality assurance and adherence of the SAFE VET protocol at each intervention site. In addition to the executive committee, clinical site leaders provide local guidance in their respective EDs. The initial evaluation of the project reported here uses quality assurance data to determine the acceptability of the intervention to veterans (as determined by willingness to receive the intervention) and the impact of intensive telephone contacts following the SAFE VET intervention in the ED (as determined by percentage of veterans who received either outpatient mental health services within 6 months or any psychiatric service within 14 days). As part of the follow-up protocol SAFE VET mainly targets transitioning veterans from the ED into outpatient mental health services, but it was also important to know whether SAFE VET veterans are getting any psychiatric services in the short-term.
Table 1 provides initial information on acceptability of the intervention and follow-up services use.
TABLE 1 Acceptability of the SAFE VET Intervention to Veterans and Follow-Up Mental Health Related Services Use
| Measure | No., Mean ±SD, or No. (%) |
| Veterans referred to the SAFE VET Demonstration Project | 471 |
| Veterans who agreed to receive the SAFE VET intervention | 438 (93) |
| Days between index ED visit and first follow-up | 4.4 ±5.5 |
| Follow-up calls made by acute services coordinators | 6.2 ±4.4 |
| Veterans who received ≥ 1 outpatient mental health follow-up visit 6 mo after SAFE VET interventiona | 379 (80) |
| Percentage of SAFE VET veterans who received any psychiatric service within 14 d of ED dischargeb | 325 (69) |
Note.ED = emergency department; SAFE VET = Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment.
a Excludes substance abuse services or admission to the ED and other VA services.
b Includes outpatient mental health, substance abuse services, or admission to the ED and other VA services.
We also found a significant difference (P < .001) in the average number of outpatient mental health visits during the 6 months after the index ED SAFE VET intervention (mean = 9.2) compared with the average number of outpatient mental health visits before the index ED SAFE VET intervention (mean = 4.9).
Although there are other promising behavioral interventions for suicidal individuals, including the Collaborative Assessment and Management of Suicidality,9 Cognitive Behavior Therapy,10 and Dialectical Behavior Therapy,11 Safety Planning should not be considered as substituting for these more intensive treatments. These interventions differ from Safety Planning in that the latter is readily accessible to patients and professionals, and in the context of a treatment trial conducted by Stanley et al., Safety Planning has been shown to be highly acceptable and feasible to implement.10
Acceptance of the SAFE VET intervention has been extremely high from the perspective of the ED or urgent care mental health providers (see sidebar). Rather than placing a burden on ED clinical providers and overstressed inpatient units, the SAFE VET intervention provides a means of assisting these providers in addressing the needs of a significant subpopulation of veterans who are suicidal but not necessarily appropriate candidates for hospitalization. A key component of the SAFE VET intervention appears to be the intensive follow-up provided by the acute services coordinator (Table 1).
One limitation of the SAFE VET program has been that potentially critical connections between the VA acute services coordinators and community settings where veterans may receive care has yet to be fully realized. We do not have information regarding why 20% of the SAFE VET veterans did not receive any mental health services within 6 months of their index ED visit. It is possible that care was delivered in non-VA settings. Whether care was provided and unknown to us or was never provided would have been critical information to obtain for this demonstration project.
Long-term evaluation of the characteristics of follow-up care is a critical first step for demonstrating the effectiveness of the SAFE VET intervention in the VA. In the general population, the time between discharge from an ED and a follow-up visit to outpatient mental health care has persistently represented a challenge in terms of continuity of care. As shown in Table 1, 80% of SAFE VET veterans received 1 or more outpatient mental health services within 6 months, (including rescheduled visits). This is compared with the reported 10% to 40% of patients who are discharged from the ED in the general population who return for a follow-up visit or a rescheduled visit.4,5,12
Although implementation of the demonstration project and quality assurance data reported in this paper reveal that acceptability of the SAFE VET intervention has been high (93% of veterans agreed to receive the SAFE VET intervention; Table 1) and provide some promising information on follow-up services use (Table 1), a research study is needed to demonstrate the effectiveness of SAFE VET on key outcomes. Such a research study is now funded (A Brief Intervention to Reduce Suicide Risk in Military Service Members and Veterans; Award Number W81XWH-09-2-0129, Military Operational Medicine Research Program, Department of Defense) and will use a quasi-experimental design to compare the effectiveness of the SAFE VET intervention versus enhanced care on the following: the proportion of patients who attempt suicide within 6 months of the index ED visit, the severity of suicide ideation within 6 months after the index ED visit, the proportion of patients who attend more than 1 outpatient mental health or substance abuse treatment appointment within 30 days after the index ED visit, the degree of suicide-related coping strategies, and the motivation to attend treatment during the 6 month period.
“To understand the systemic effect of SAFE VET, I believe it is necessary to put oneself in the place of a frontline clinician in the emergency department who is seeing a patient with suicidal ideation. Such a clinician would be weighing multiple factors and priorities as they make the difficult decision to recommend discharge or admission. My initial impression was that when confronted with this choice, it seemed to be routine practice to suggest voluntary admission to almost every patient who presented with suicidal ideation regardless of the level of severity. Although this is a cautious approach, I wonder how such admissions affect a person who had never been psychiatrically hospitalized. I believe SAFE VET creates a third category of response that fits between discharge and admission. It allows the clinician to respond to the patient’s at risk for suicide by implementing safety planning, and allowing the patient to leave the emergency department with some tangible plan for how they are going to cope, and people who they can contact. This seems to me to be a very appropriate response to patient’s with non-acute suicidal ideation.” (an acute services coordinator)
This future study will recruit up to 600 veterans for each condition and will include assessment at baseline (index ED visit) and 1, 3, and 6 months after the index ED visit to complete the follow-up research measures. If this future research finds that the SAFE VET intervention is effective on key outcomes such as suicide attempts, suicidal ideation, and engagement in care, the approach may be transferable to a wide variety of VA and non-VA settings, including community emergency departments and urgent care centers.
Acknowledgments
The Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment (SAFE VET) project is supported by the Office of Mental Health Services, Department of Veteran Affairs.
Ira Katz, MD, PhD, provided valuable insight into the design of the project. The SAFE VET group consists of an executive committee (Kerry L. Knox, Gregory K. Brown, Glenn W. Currier, Barbara Stanley), site leads (Lisa Brenner, PhD, Joan Chips, LCSW, Joshua Hooberman, PhD, Christine Jackson, PhD, Mitchel Kling, MD, Keith Rogers, MD), and acute services coordinators (Patricia Alexander, PhD, Laura Blandy, PsyD, Aimee Coughlin, MSW, John Dennis, PhD, Michael Miello, PhD, Katherine Mostkoff, LCSW and Jarrod Reisweber, PsyD). We would like to acknowledge key individuals who facilitated implementation of SAFE VET and provided essential guidance: Lauren Denneson, PhD, Steven Dobscha,MD, Walter Matweychuk, PhD, Gerd Naydock, MSW, Keith Rogers, MD, Donald Tavakoli, MD, and Adam Wolkin, MD
Human Participant Protection
Institutional review board approval was not required because no human participants were involved.
