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Published in final edited form as: J Psychopathol Clin Sci. 2025 Jan 16;134(3):217–227. doi: 10.1037/abn0000968 Search in PMC Search in PubMed View in NLM Catalog Add to search Suicide risk assessment and management protocol for research within the Department of Veterans Affairs Emily R Edwards Emily R Edwards , PhD 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY 2 Department of Psychiatry, Yale School of Medicine, New Haven, CT Find articles by Emily R Edwards 1, 2 , Grace N Anderson Grace N Anderson , MA 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY 3 Department of Psychology, Fordham University, Bronx, NY Find articles by Grace N Anderson 1, 3 , Emilia M Fonseca Emilia M Fonseca , BS 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY Find articles by Emilia M Fonseca 1 , Amanda L Reed Amanda L Reed , PhD 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY Find articles by Amanda L Reed 1 , Chi Chan Chi Chan , PhD 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY Find articles by Chi Chan 1 , Erin A Hazlett Erin A Hazlett , PhD 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY 4 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY Find articles by Erin A Hazlett 1, 4 , Joseph C Geraci Joseph C Geraci , PhD 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY 5 VISN 17 Center of Excellence, Department of Veterans Affairs, Waco, TX Find articles by Joseph C Geraci 1, 5 , Marianne Goodman Marianne Goodman , MD 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY 4 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 5 VISN 17 Center of Excellence, Department of Veterans Affairs, Waco, TX Find articles by Marianne Goodman 1, 4, 5 Author information Article notes Copyright and License information 1 VISN 2 Mental Illness Research, Education, and Clinical Center, Department of Veterans Affairs, Bronx, NY 2 Department of Psychiatry, Yale School of Medicine, New Haven, CT 3 Department of Psychology, Fordham University, Bronx, NY 4 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 5 VISN 17 Center of Excellence, Department of Veterans Affairs, Waco, TX ✉ Corresponding Author : Emily Edwards, PhD; [email protected] ; James J. Peters VA Medical Center, VISN-2 MIRECC, 130 W Kingsbridge Road, Bronx, NY 10468 Issue date 2025 Apr. PMC Copyright notice PMCID: PMC11949709 NIHMSID: NIHMS2057358 PMID: 39818840 The publisher's version of this article is available at J Psychopathol Clin Sci Abstract Escalating rates of suicide among United States military Veterans have prompted the Department of Veterans Affairs (VA) to prioritize Veteran suicide as a chief clinical concern. VA-funded research is consistently dedicated to suicide prevention initiatives, reflecting a commitment to addressing this urgent issue. Although general guidelines have been proposed for recognizing and responding to suicide risk among research participants, to date, no guidelines have been published that are Veteran-specific. Veterans exhibit unique suicide risk factors compared to civilians, including higher rates of suicide, a tendency to utilize more lethal means when attempting suicide, and substantial stigma surrounding mental health and help-seeking, underscoring the need for Veteran-specific suicide risk assessment and management protocols (SRAMs). This manuscript offers a comprehensive SRAM to guide research with Veteran participants. The protocol provides guidance on (a) accurate assessment of suicide risk, (b) risk management strategies commensurate to presenting risk, and (c) tailoring SRAMs for diverse study designs and contexts. By introducing this standardized, Veteran-focused SRAM, we aspire to bolster ongoing research dedicated to saving the lives of Veterans. Keywords: Veteran, suicide, risk assessment, risk management, research protocol General Scientific Summary: Military Veterans are at exceptionally high risk for suicide-related behaviors and tend to experience unique suicide risk factors compared to civilians. This manuscript outlines a suicide risk assessment and management protocol to guide research being conducted with Veteran populations. Suicide among military Veterans is a public health emergency in the United States ( Department of Veterans Affairs [VA], 2023a ). Since the early 2000s, Veteran suicide rates exceed those of civilians; in 2021, the age- and sex-adjusted Veteran suicide rate was 72% greater than that of non-Veteran adults ( VA, 2023a ). Veteran suicide is therefore the top clinical priority of the VA ( VA, 2023a ). Accordingly, the President’s 2023 budget allocated $497 million to support VA Veteran suicide prevention initiatives ( VA, 2023b ), and suicide is routinely prioritized in VA-funded research ( VA, 2024a ). To support ethical design and execution of suicide-focused research, protocols include ongoing assessment and management of participant suicide risk. Suicide-risk assessment and management protocols (SRAMs) provide standardized guidelines and procedures for recognizing, evaluating, and responding to suicide risk. Institutional review boards (IRBs) prioritize SRAMs. When deemed insufficient, SRAMs pose barriers to IRB evaluation and approval due to concerns about potential adverse events, threats to participant safety, and liability ( Hom et al., 2017 ). When designed appropriately, however, these protocols ensure safety of research participants and, by extension, success of research itself. Research on Veteran suicide highlights a need for Veteran-specific SRAMs. Veterans are disproportionately more likely than civilians to experience various suicide risk factors, including exposure to traumatic events ( Lehavot et al., 2018 ), mental and physical health concerns ( Lehavot et al., 2012 ), familiarity with and access to lethal means (e.g., firearms; Theis et al., 2021 ), and limited social support ( Campbell et al., 2021 ). Veteran suicide attempts are also more likely to involve firearms, increasing risk of serious injury and/or death ( VA, 2023a ). Due to military stigma surrounding mental health, suicide, and help seeking, many Veterans are hesitant to disclose suicidal ideation ( Ammerman et al., 2022 ; Sharp et al. 2015 ). Veterans’ disclosure experiences are also significantly associated with motivation for future disclosure ( Ammerman et al., 2021 ); therefore, researcher responses to suicide-related disclosures could impact validity of future risk assessments. SRAMs for Veteran-focused research must be sensitive to at-risk Veterans’ unique needs and capable of detecting and responding to increased risk swiftly, effectively, and in a manner Veterans experience as productive, collaborative, and non-coercive. Many research SRAMs and SRAM clinical practice guidelines have been developed (e.g., Luxton et al., 2014 ; VA & DoD, 2024 ). However, SRAMs for civilian populations do not typically consider Veteran-specific risk factors (e.g., military stigma) nor integration between SRAM and Veteran-specific resources (e.g., VA-based care). Clinical practice guidelines are also intended for clinical applications and therefore offer expectations that may be unrealistic for research settings (e.g., increasing frequency of contact; VA & DoD, 2024 ). Thus, although such resources may be helpful, their applicability to Veteran-focused research is limited. As leaders in Veteran-focused suicide research, the VISN 2 Mental Illness Research, Education, and Clinical Center (MIRECC) routinely enrolls Veterans across the suicide-risk spectrum. A standardized SRAM was developed to support these efforts, which include neurobiological studies, clinical trials, and program evaluations. This SRAM is outlined here as a guide for Veteran-focused research, including studies with and without a primary suicide focus. It is intended to provide researchers who are new to suicide research an outline of necessary elements and considerations for an effective Veteran-specific SRAM and to provide more experienced researchers a quick reference for reviewing and updating their own SRAMs. It complements existing materials (previously published SRAMs, clinical practice guidelines, etc.) by highlighting factors most relevant to SRAM in Veteran research and directing researchers to resources offering more detailed guidance. Our approach is informed by previous research on SRAM development as well as the VHA Memorandum 2022–11–23 Eliminating Veteran Suicide; VA and Department of Defense (DoD) Clinical Practice Guidelines ( VA & DoD, 2024 ); guidance by the VA Suicide Prevention Research Impact NeTwork ( SPRINT; VA, 2022 ); and The Joint Commission standards for screening and evaluating suicide risk, NPSG.15.01.01 EP2 and EP3 (2018). The interested reader is encouraged to consult these sources for more nuanced guidance as they finalize their own SRAM. The foundational protocol outlined here is designed primarily for research involving in-person protocols with singular participants. Procedures, structures, and local-site requirements of individual studies may necessitate adaptation. Common adaptations, including those for multiple participant contacts, clinical trials, group-based participation, participation over virtual platforms, and non-traditional research settings are discussed toward the end of this manuscript. SUICIDE RISK ASSESSMENT PROTOCOL Successful SRAMs first require accurate identification of risk among research participants. Unstructured, clinical judgments of suicide risk are often unreliable and potentially biased, leading many to advocate for structured, actuarial risk assessments ( Ægisdóttir et al., 2006 ; Berman et al., 2015 ). Nevertheless, clinical judgments are also statistically significant predictors of future suicidal thoughts and behaviors, even after controlling for predictive validity of structured assessments ( Barzilay et al., 2018 ). Leading guidelines therefore suggest a combination of structured assessment and clinical judgment in assessing Veteran suicide risk ( VA & DoD, 2024 ). Suicide Risk Screening & Assessment For studies anticipating generally low suicide risk among participants (e.g., survey of community-based Veterans), brief suicide risk screening using Question 9 of the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001 ) - “Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself?” scored on a scale of 0 (not at all) to 3 (nearly every day) - is often sufficient to determine whether a participant requires comprehensive suicide risk assessment. Administration is efficient, avoiding undue participant burden in contexts where participant risk is anticipated to be generally low. Veteran responses are also significantly associated with likelihood of later death by suicide, highlighting its utility as a valuable screening tool ( Louzon et al., 2016 ). Screening is completed within the first study visit and after sufficient rapport has been built, thereby encouraging accurate reporting. If a participant endorses suicidal ideation via the PHQ-9 screener item (i.e., score higher than 0), further assessment to determine the nature, acuity, and chronicity of the ideation is completed before ending the study session to guide risk management. Notably, this sometimes requires study sessions to be extended beyond original scheduling. See Supplemental Figure 1 for an example of how to schedule SRAM procedures within a study session. Studies with an explicit focus on Veteran suicide, that explicitly recruit Veterans at risk for suicide, and/or include comprehensive suicide risk assessment as part of broader study procedures may bypass screening altogether and instead begin with more thorough assessment for efficiency. Generally, such assessment is completed using the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008 ) or C-SSRS Screen Version ( Posner et al., 2011 ) to assess current suicidal ideation. The C-SSRS takes approximately five minutes to administer and provides a structured approach to assessing suicide risk severity and acuity through standardized questions about suicide-related thoughts and behaviors ( Posner et al., 2008 ). It is a key component of the VA’s national, standardized approach to Veteran suicide risk screening and evaluation ( Gujral et al., 2023 ). Among Veterans identified as at-risk for suicide, C-SSRS demonstrates strong convergent, divergent, and predictive validity, with responses predicting later suicide preparatory behaviors and attempts ( Katz et al., 2020 ; Matarazzo et al., 2019 ). Our utilization of C-SSRS stands in contrast to many research SRAMs that instead rely on templated questions about suicide-related thoughts and behaviors and structured decision trees ( Stevens et al., 2021 ). These alternatives require considerably less training and streamline risk assessment procedures, making them more accessible for junior staff. However, they are not widely validated and may not yield as accurate information as the C-SSRS. Researchers are therefore strongly recommended to utilize the C-SSRS (or another validated suicide risk assessment) as part of SRAMs. For participants endorsing only “Wish to be Dead” or “Non-Specific Active Suicidal Thoughts” (C-SSRS items 1 and 2, respectively), more comprehensive assessment is not typically required. These participants are reminded of available resources for managing suicide-related thoughts and behaviors (e.g., national crisis lines, local mental health services), and risk is monitored through future study sessions, if applicable. Participants endorsing active suicidal ideation with method, intent, and/or plan (C-SSRS items 3, 4, and/or 5) are further assessed using the VA Comprehensive Suicide Risk Evaluation (CSRE). The CSRE provides a semi-structured framework to guide clinical judgment through consideration of suicide-related behavior history and presence or absence of current risk and protective factors. Completion time is approximately 10–30 minutes depending on complexity of risk presentation. The CSRE was designed with special consideration of factors particularly relevant to Veteran risk, including access to lethal means, recent discharge from military service, and trauma history. Following completion, information from the C-SSRS and CSRE are integrated to guide clinical determinations of suicide risk acuity and chronicity, which guide subsequent risk-management strategies. To date, research has not explicitly examined the psychometric quality of the CSRE. See Figure 1 for a summary of suicide-risk assessment protocols. Figure 1. Open in a new tab Suicide Risk Assessment Protocol Risk Acuity & Chronicity In 2024, VA and DoD updated clinical practice guidelines for assessing and managing military personnel suicide risk (for a summary, see VA & DoD, 2024 ). Conceptualization of suicide risk according to risk acuity and chronicity is a key component of these guidelines. Briefly, risk acuity reflects likelihood of imminent suicide-related behaviors, whereas risk chronicity reflects long-term propensity for experiencing increase(s) in risk acuity. Although each exist along a continuous spectrum, they are stratified into low, intermediate, and high strata for SRAM purposes. Common factors guiding risk acuity determinations include nature/recency of suicidal ideation/behavior, acute psychosocial stressors, acute mental health/mental status, access to lethal means, identified reasons for living, demonstrated coping ability, ability to independently maintain safety, and connection to close others to support safety. Common factors guiding risk chronicity determinations include history of suicidal ideation and self-directed violence, substance use, chronic mental/medical illness or pain, impulsivity, psychosocial stability, identified reasons for living, and demonstrated ability to endure crisis without resorting to self-directed violence. Determinations are informed by the Veteran’s individual circumstances. For a summary, see Table 1 . Table 1: Suicide Risk Acuity & Chronicity Risk Level Essential Features Common Features Acute Risk Low • Passive or no suicidal ideation • Ability to maintain safety independently • Multiple protective factors Intermediate • Suicidal ideation with at least some intent • Ability to maintain safety without external support • Ambivalent intent • Multiple protective factors High • Suicidal ideation with clear intent and/or plan • Inability to maintain safety without external support • Suicide plan • Recent attempt or preparatory behaviors • Acute exacerbation of mental illness • Access to lethal means • Acute psychosocial stressors Chronic Risk Low • Demonstrated ability to endure crisis without resorting to self-directed violence • No history of self-directed violence, chronic suicidal ideation, impulsivity, or recurrent risky behavior Intermediate • Demonstrated ability to endure crisis without resorting to self-directed violence • Chronic suicidal ideation, major mental illness, and/or personality disorder • History of suicide attempt(s) • History of substance abuse • Chronic pain and/or medical condition High • Demonstrated inability to endure crisis without resorting to self-directed violence • Chronic suicidal ideation, major mental illness, and/or personality disorder • History of suicide attempt(s) • History of substance abuse • Chronic pain and/or medical condition • Limited coping skills • Psychosocial instability • Limited identified reasons for living Open in a new tab Ongoing Suicide Risk Monitoring Protocols involving multiple participant contacts require ongoing monitoring of participant risk. Suicide risk is fluid, characterized by a constant ebb and flow of interaction between risk and protective factors ( Kivelä et al., 2022 ). Therefore, ongoing monitoring is necessary to ensure continued safety of participants, particularly those identified as at risk for suicide. Ongoing monitoring includes routine check-ins with and/or assessment of participants’ potential risk and protective factors (e.g., introduction of new life stressors) and can take many forms, including formal assessments, brief screening instruments, conversations with participants, or review of session notes. Monitoring prompts completion of a formal suicide risk assessment (i.e., C-SSRS and, as necessary, CSRE), as described above, when there is a clinically meaningful change in identified risk and/or protective factors. Many Veterans are hesitant to disclose suicidal ideation and intent ( Ammerman et al., 2022 ; Sharp et al. 2015 ). Because of these hesitations, researchers adopt a lower threshold for completing formal suicide risk assessments when working with Veteran participants than is typically adopted in civilian-focused research. For example, whereas civilian-focused research often relies on spontaneous suicide-related disclosures or significant changes in risk and protective factors among persons already identified as at risk to prompt formal assessment (e.g., Erbacher & Singer, 2018), Veteran-focused research considers formal assessment in response to even moderate changes in risk and protective factors regardless of whether the Veteran makes a suicide-related disclosure and/or has already been identified as at risk. Researchers also avoid considering a lack of expressed suicidal ideation (or outright denial of suicidal ideation) as sufficient reason for choosing not to complete a risk assessment. Ongoing risk monitoring requires research staff to be familiar with participants’ preexisting suicide risk and relevant risk and protective factors, because acute changes in risk and protective factors (e.g., new legal charges, loss of social support) signal possible corresponding changes in risk acuity ( VA & DoD, 2024 ). Researchers utilizing ongoing risk monitoring procedures therefore maintain internal records (e.g., notes about pre-existing risk and protective factors) regarding participant risk to support these procedures. Administer Within the Context of Rapport Veteran hesitations around disclosure of suicide risk can be mitigated when risk assessments are completed by providers perceived as trustworthy, empathic, understanding, and collaborative ( Ammerman et al., 2021 ). However, military-civilian cultural differences, perception of civilians as incapable of understanding Veteran experiences, and deep-rooted privacy concerns often pose barriers to effective rapport-building with Veterans ( Edwards et al., 2023b ). Researchers may mitigate these barriers by increasing military and Veteran cultural competence (e.g., knowledge of service branches), adopting an interpersonal style that mimics military culture (e.g., direct, authentic, validating), and explicitly orienting to privacy protection practices ( Edwards et al., 2023b ). To foster rapport specifically within SRAM, researchers also: (a) provide context prior to questions related to suicide, including reasons for assessment, potential consequences of disclosure (e.g., limits to confidentiality), and clarity around when consequences are deemed necessary; (b) offer ample expressions of emotional validation and empathy throughout SRAM; (c) delay administration of risk assessments until rapport can be built (but always before the end of first participant contact); and (d) maintain a collaborative stance throughout implementation of SRAMs. Example language to guide development of rapport with Veteran participants is available from VA SPRINT ( VA, 2022 ). Who Completes Risk Assessments Study protocols are often executed by research assistants or trainees, some of whom have limited prior SRAM experience. In general, all staff responsible for interacting with study participants are trained in Veteran cultural competency, recognizing Veteran suicide risk and protective factors, and administration and interpretation of included risk assessments. At minimum, training includes completion of formal C-SSRS training (available through Columbia Lighthouse Project), didactic lectures, pedagogical role plays, shadowing or otherwise observing SRAMs, and routine reviews of SRAM proficiency, competency, and fidelity. Should a risk assessment require CSRE completion, a licensed clinician is required. CSREs must be completed before ending the research assessment session to allow efficient implementation of necessary risk-management strategies. To support ongoing training efforts, the clinician’s involvement may be graded according to staff training, experience, and competency. Notably, these procedures require at least one clinician to be “on call” whenever participants are completing study procedures. Even when involving a clinician, priority is placed on maintaining rapport to promote risk assessment validity ( Ammerman et al., 2021 ). This is particularly important in work with Veteran participants, as Veterans are often slow to build rapport ( Edwards et al., 2023b ) and may struggle to transfer rapport between staff members ( Koenig et al., 2013 ). Participants are therefore provided rationale for involving a supervisory clinician, the supervisory clinician’s role, and next steps involved. The staff with whom participants begin SRAMs remains involved even after including the supervisory clinician regardless of the clinician’s involvement. Through this continued involvement and support, the research staff allows participants to feel validated and cared for (rather than abandoned or betrayed). SUICIDE RISK MANAGEMENT PROTOCOL Suicide-risk management within research requires special consideration because research contexts do not typically provide the continuum of risk management resources or ongoing monitoring inherent to healthcare settings. Roles and responsibilities of researchers to manage participant risk are also narrower than those of healthcare providers. Whereas providers are liable and ethically responsible for ensuring provision of appropriate care, the researcher’s role is limited to “that of an informed gatekeeper who routinely (a) takes appropriate actions to assess and categorize a participant’s risk, and (b) then [connects] the participant with appropriate services rather than serving as the de facto provider of those services” ( Hom et al., 2017 , p. 108). Apart from initiating emergency services involvement, it is typically beyond a researcher’s traditional role to ensure connection of participants with recommended risk-mitigating resources or services. Consistent with VA/DoD clinical practice guidelines ( VA & DoD, 2024 ), suicide risk management is graded according to risk acuity and chronicity. This facilitates only the minimum level of intervention necessary to ensure participant safety and reserves more intrusive interventions for extreme circumstances. Given disproportionately high rates of trauma exposure among Veterans ( Lehavot et al., 2018 ), researchers adopt a trauma-informed approach to suicide risk management by promoting a sense of transparency and safety, adopting a collaborative stance, and empowering Veteran participants to take lead, as feasible, in choosing risk mitigation strategies that best align with their needs. When risk assessment suggests risk management strategies are needed, such strategies must be implemented before ending participant contact. Upon successful risk mitigation, study procedures may typically resume. See Figure 2 for a summary of risk-management strategies corresponding to acuity/chronicity risk strata. Figure 2. Open in a new tab Suicide Risk Management Protocol; informed by 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines ( VA & DoD, 2024 ) VA-Specific Risk Management Resources Consistent with VA prioritization of suicide prevention, several risk-management resources are available throughout the VA. Effective risk management relies on efficient connection of at-risk Veterans to resources. (This discussion is not intended as a comprehensive review of all VA-based resources; instead, it highlights resources most often utilized within Veteran-specific research SRAMs.) Veterans Crisis Line (VCL) is a free, national, 24-hour hotline service available to Veterans experiencing mental health or other crises. Veterans may call, text, or chat with VCL to connect with an on-call crisis line responder. Responders use evidence-based standards of care and access to Veterans’ VA electronic health records to reduce immediate distress, connect Veterans with services, and coordinate care with local VA medical centers. Veterans are generally satisfied with VCL services and typically experience reduced distress, suicidal ideation, and suicidal urgency by the call’s end ( Britton et al., 2022 ; Johnson et al., 2021 ). As another resource, Suicide Prevention Coordinators (SPCs) are VA-based clinicians who facilitate suicide-prevention initiatives at each VAMC. SPCs are considered the facility subject matter expert on SRAM. They are available to provide consultation to study clinicians, facilitate care coordination for at-risk Veterans, and assist implementation of risk management strategies. Due to their role, SPCs are also uniquely situated to provide updated information about resources and programs to support risk assessment and management, such as the VA Suicide Prevention 2.0 Initiative (offering specialized telehealth services to at-risk Veterans), Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment program (a program using predictive analytics to identity Veterans at potential risk for suicide; Matarazzo et al., 2023 ), Together with Veterans program (providing support to at-risk Veterans in rural areas; Monteith et al., 2020 ), and local community-based resources. Connection with SPC services is associated with lower odds of suicide attempts and self-directed violence ( Doran et al., 2021 ). Risk Management by Level of Acuity Suicide risk acuity guides risk management strategies that promote immediate participant safety and is therefore the focus of most research SRAMs. In general, individuals at low-acute risk require no intervention to ensure continued safety, and study protocols may proceed with these participants without interruption. When a participant presents with intermediate-acute risk, researchers utilize suicide safety planning (SSP; see Suicide Safety Planning ) to collaboratively build a suicide safety plan and assess the participant’s ability to maintain safety ( Stanley & Brown, 2012 ). Because many Veterans have ready access to potentially lethal means, particularly firearms, Step 6 of SSP also includes lethal means safety counseling (LMSC) to reduce access during times of crisis. Extensive emotional validation is offered throughout completion of these protocols, because validation – even in isolation of other interventions – is often effective in decreasing acute suicide risk among research participants ( Ward-Ciesielski & Wilks, 2020 ). If the participant appears able to maintain safety, the researcher provides resources (e.g., contact information, brochures, etc.) for connecting to mental health care for follow-up assessment and as-needed services. Participants already connected to outpatient services are encouraged to follow-up promptly with existing providers. Researchers may facilitate such follow-up as needed by assisting with and/or observing participant contact with providers in real time and/or coordinating directly with outside providers. If a participant appears unable to confidently maintain their safety ( high-acute risk ) or there is question about the participant’s ability to maintain safety, researchers initiate a warm handoff to the nearest emergency department (ED) for further evaluation in accordance with local procedures. The local SPC (and outside providers, as feasible) is also notified to aid subsequent care coordination. Participant responses to handoff can vary widely, from relief to anger, betrayal, and devaluing ( Akther et al., 2019 ). Experiences of inpatient admission as compulsory are associated with later perceptions of mental health care as coercive and decreased motivation to seek psychiatric care ( Danzer & Wilkus-Stone, 2015 ; Newton-Howes & Mullen, 2011 ). Researchers therefore encourage participants to self-initiate ED care where possible, thereby promoting participant independence and dignity. However, integration of other supports, such as emergency medical services, police, security personnel, and/or emergency contact(s), may also be used as needed to ensure connection to ED care. The research team remains involved in the handoff until connection to ED care is confirmed. Risk Management by Level of Chronicity Suicide risk chronicity guides longer-term preventative strategies. Regardless of chronic risk strata, all participants are provided information, typically through debriefing procedures, about preventative resources and services (e.g., local VA outpatient mental health departments, EDs, VCL) to aid chronic risk mitigation. Because participants at low-chronic risk are unlikely to experience future escalations in risk acuity, this universal approach is typically sufficient for these participants. By contrast, participants at intermediate- or high-chronic risk typically require SSP and LMC to facilitate longer-term risk mitigation. Suicide Safety Planning SSP is commonly integrated into risk management protocols, particularly for participants with at least intermediate-acute or intermediate-chronic risk for suicide. Adherent SSP can help reduce future suicide-related outcomes, including psychiatric hospitalization, self-harm behavior, and suicide attempts ( Ferguson et al., 2022 ). The VHA therefore mandates all Veteran clients identified as at risk for suicide be provided this intervention as part of standard clinical care ( VA & DoD, 2024 ). The intervention is generally brief, lasting approximately 30 minutes, and involves collaboratively building an individualized list of seven steps to mitigate suicide risk in the event of future crisis (for a summary, see Stanley & Brown, 2012 ). The participant is provided a copy of the completed plan and encouraged to store it for easy reference in times of need (e.g., in a bedside table, as a bookmarked photo on their phone). A copy of the completed plan is also entered into the participant’s VA electronic medical record using designated note templates, making it accessible to VA providers. Notably, because of its routine administration within the VHA, many at-risk Veterans may have copies of previously completed Suicide Safety Plans already documented within their VA electronic medical record. For these Veterans, researchers may collaboratively review and update previously completed plans rather than create new plans from scratch. Despite the national VA mandate to integrate SSP into standard clinical care, research reflects ranging quality in implementation and a direct association between implementation quality and intervention effectiveness ( Gamarra et al., 2015 ; Green et al., 2018 ). Completeness and personal relevance of safety plans appear particularly important for ensuring maximum benefit ( Gamarra et al., 2015 ; Green et al., 2018 ). Researchers using SSP must therefore have comprehensive training in proper execution, such as those offered through the VA or Center for Practice Innovations ( https://practiceinnovations.org/resources/scorm/safety-planning ). Regular fidelity monitoring may be used to ensure adherence to the intervention protocol. Of note, Step 6 of SSP includes LMSC. In 2021, 72% of Veteran suicides involved firearms (versus 52% of civilian suicides; VA, 2023a ), attesting to the need to protect at-risk Veterans from firearm-related self-injury. LMSC provides psychoeducation about dangers of lethal means access and collaborative problem solving to reduce immediate access. Ample evidence reflects effectiveness of LMSC in reducing risk for suicide and other self-directed violence ( Spitzer et al., 2024 ). Like other suicide-prevention interventions, LMSC is most effective when delivered within the context of rapport and genuine expressions of concern, including explicit discussions of confidentiality, and tailored to the Veteran’s unique needs and circumstances ( Hoyt et al., 2021 ). Military culture values firearm ownership as central to one’s identity, often creating a cultural divide between Veterans and those delivering LMSC, sometimes posing a barrier to successful counseling ( Pruitt et al., 2022 ). Some Veterans respond negatively to discussions about firearm safety and are reticent to engage in LMSC, and many clinicians are similarly reluctant to deliver LMSC ( Hoyt et al., 2021 ). Research teams are therefore encouraged to pursue additional training and resources to support LMSC efforts, such as the BulletPoints Project ( https://www.bulletpointsproject.org/ ) or Counseling on Access to Lethal Means ( https://www.calmamerica.org/ ). Coordination with Existing Providers Particularly in studies explicitly recruiting Veterans experiencing mental or physical health-related difficulties or other stressful circumstances, participants are often actively engaged with mental healthcare at the time of participation. In these cases, SRAM may necessitate time-limited care coordination with existing providers – a potential discussed during informed consent. Connection to mental healthcare can generally be considered protective against suicide risk provided such connection is consistent and providers are aware of the Veteran’s risk ( Huggett et al., 2022 ). When these conditions are not met, most typically due to poor rapport, concerns about consequences of disclosure, and/or perceptions of provider(s) as unavailable ( Ammerman et al., 2021 ; Ammerman et al., 2022 ; Sharp et al. 2015 ), active coordination between researchers and providers can significantly support participant safety. Researchers may, for example, actively facilitate disclosure of risk to providers by coordinating contact with providers in real time, documenting risk in electronic medical records, and/or communicating directly with providers. Throughout coordination, researchers maintain a collaborative, transparent, and trauma-informed approach. Coordination with existing providers also becomes necessary when participants are at high risk and/or referred for inpatient/ED evaluation. Under these circumstances, existing providers and SPCs are a valuable source of information and ongoing support to guide long-term risk management and care coordination. Many providers strongly prefer to be involved in initiation of emergency services and/or referrals to inpatient care ( Schatten et al., 2020 ). Researchers therefore notify existing providers and SPCs of participants at high-acute risk and strive to involve these providers into risk management strategies as early as feasible. Care coordination can often benefit from VHA’s electronic health record system (EHS). Using EHS, researchers can enter research notes into Veterans’ medical charts to document consent, participation details, suicide risk monitoring results, etc. VA providers can be added as co-signers to notes containing information pertinent to care (e.g., risk assessment results, implementation of risk-management procedures); by co-signing notes, providers acknowledge receipt of information contained therein. Notes entered within EHS are typically available to all VA providers involved in the Veteran’s care, including those within the VHA and Veterans Benefits Association. Studies utilizing EHS therefore clearly disclose documentation etiquette during consenting procedures. SPECIAL CONTEXTS Although all studies share a similar foundational SRAM, unique contexts of some studies require adaptations 1 . Of note are those involving multiple participant contacts, clinical trials, group-based procedures, virtual participation, and participation outside traditional research settings. Multiple Participant Contacts Some studies include multiple participant contacts, creating an ongoing relationship between researcher(s) and participants at least for the duration of participation. Researchers are responsible for ensuring participant safety at each study session (though typically rely on outside support and/or resources to ensure safety between scheduled contacts). SRAMs for multiple participant contacts therefore require inclusion of ongoing formal and/or informal suicide risk monitoring throughout the duration of study procedures (see Ongoing Suicide Risk Monitoring ). Research involving multiple participant contacts and likely to enroll Veterans at intermediate- or high-chronic risk for suicide also commonly requires participants to identify an emergency support person (ESP). The ESP is documented at consent and is typically a close friend or family member. If an active participant is believed to be at risk for suicide and cannot be reached by research staff (e.g., does not arrive for a scheduled contact and/or is unresponsive to outreach attempts), the ESP may be contacted to facilitate connection with the Veteran for risk assessment (thereby avoiding involvement of emergency services). Veterans may also opt to have ESPs involved in coordinating resources and services (e.g., presentation at an ED) in the event of emergency. Due to elevated rates of social isolation among Veterans, particularly those at risk for suicide ( Campbell et al., 2021 ), many participants may be unable to identify an ESP. In these circumstances, VCL may be used in place of ESPs. Clinical Trials Within clinical trials, roles and ethical responsibilities of researchers often expand to include clinical responsibility for participant safety and wellbeing. This is particularly true for trials involving delivery of intervention functioning as a primary treatment (versus intervention provided adjunctive to standard care). Clinical trial SRAMs are therefore more robust and nuanced than standard research SRAMs. First, because clinical trials often involve multiple participant contacts, trial SRAMs typically integrate accompanying adaptations (i.e., ongoing risk monitoring and identification of ESPs). Such adaptations are consistent with broader VA clinical guidelines surrounding the care of at-risk Veterans ( VA & DoD, 2024 ), previously published clinical trial guidelines ( Schatten et al., 2020 ), and ongoing clinical trials comparing interventions to mitigate suicide risk ( Weinstock et al., 2024 ). Second, clinical trial SRAMs monitor and mitigate chronic risk of participants by (a) checking in with higher-risk participants as needed between regularly scheduled contacts, and (b) ensuring continuity of care for higher-risk participants who complete or drop out of treatment (Luxton et al., 2021). Ensuring continuity of care is especially important when experimental interventions are a primary form of treatment; however, it is also considered for adjunctive interventions. Maintaining continuity of care typically involves facilitating connection to and/or coordinating care with outside providers and is traditionally guided by VHA policies, guidelines, and mandates (e.g., Gujral et al., 2023 ). It therefore requires trial researchers to maintain close relationships with local providers and to remain current on VHA clinical requirements. For clinical trials focused on suicide or other high-risk behaviors, this care coordination may be extensive, warranting standardization within the trial protocol (e.g., Edwards et al., 2023b ). Notably, ensuring continuity of care often involves introducing additional services (e.g., care coordination) or interventions (e.g., those provided by outside providers) that participants may not otherwise receive if not enrolled in the trial ( Schatten et al., 2020 ) and are therefore considered when interpreting study findings. Third, clinical trial researchers monitor potential impacts of experimental interventions on participant risk for suicide. To support this, suicide risk is screened at every study visit, and participants are prompted to provide frequent feedback about their experience with research procedures. If an intervention appears to worsen risk for suicide, all study procedures are at least temporarily paused until the participant can be removed from the study, risk can be mitigated, and potentially iatrogenic components of the intervention can be identified and remediated. Group Participation Group-based research protocols pose unique challenges due to reliance of SRAMs on confidentiality. To overcome these challenges, brief suicide risk screens may be completed with participants individually prior to group-based participation. Screens can then be reviewed, prompting as-needed SRAM prior to group-based participation. This adaptation protects confidentiality throughout the screening process and allows all participants to be screened efficiently, without substantial burden or interruption to broader study protocols. However, it also requires participants be available for as-needed follow-up to screeners and flexibility by the researcher to divert time and resources away from research protocols when required. Delivering group-based protocols by at least two research staff can provide this needed flexibility in responding to immediate risk concerns. Similarly, if suicide risk becomes a concern during a group-based procedure and immediate follow-up SRAM is necessary, one staff member can proceed with the at-risk participant individually while the second staff member continues broader study protocols with the remainder of the group. This allows low-risk participants to continue group-based protocols with limited interruption and at-risk participants to continue SRAM with a staff member with whom they have established foundational rapport. Where feasible, at-risk participants are not transferred to an “on call” staff member with whom the participant does not have rapport; doing so may limit validity of resulting risk assessments ( Ammerman et al., 2021 ). Virtual Participation Virtual studies include completion of study procedures (e.g., consenting, study assessments, experimental interventions) over video conferencing or other online platforms. The VA has established contracts with various virtual platforms (e.g., Qualtrics, WebEx, DocuSign) and makes these available to researchers to ensure appropriate privacy protections for virtual studies. Comprehensive discussion of strategies for assessing and monitoring risk virtually are available elsewhere (e.g., Luxton et al., 2014 ; Michaels et al., 2015 ). This discussion outlines strategies commonly used when interacting with Veteran participants over virtual platforms. In accordance with broader VA clinical guidelines, researchers confirm the participant’s location and call-back number at the beginning of each virtual session. This information is used to reconnect with participants in case of technological failure and to facilitate as-needed risk management (e.g., dispatching emergency medical services). Relatedly, researchers store and maintain contact information for local emergency services and SPCs specific to each participant’s location, thereby allowing for efficient integration of such services into risk management strategies. VCL is a helpful resource for supporting this integration. Researchers also ensure availability of secondary communication lines to facilitate effective virtual SRAMs (e.g., to call supervisory clinicians, ESPs, VCL, emergency services, etc.; VA, 2022 ). At-risk participants are never placed “on hold” or disconnected from a call so staff can contact or coordinate with outside supports. Similarly, if risk management requires involvement of emergency services, staff remain on the line with the participant until emergency services arrive. If remaining on the line is not feasible, staff may facilitate a warm handoff to VCL so a crisis line worker can wait with the participant until emergency services arrive. When suicide risk screeners are completed as part of online assessments, including ecological momentary assessment (EMA) protocols, participants are informed that responses may not be monitored in real time. Therefore, instructions for contacting local supports (e.g., VCL, emergency services) must always be integrated into online assessments. Participants are also oriented to procedures around follow-up contact, if applicable, for online suicide risk screeners, including conditions that trigger follow-up, expected timeline of follow-up contacts (ideally, within 1 business day, though briefer follow-up times should be used for studies enrolling at-risk Veterans), and the nature of follow-up contacts. Where possible, researchers design online survey platforms to trigger automated instructions for respondents to seek support when responses indicate potential elevations in risk and automated notifications to alert study staff of concerning responses, thereby facilitating the timeliness of risk identification and follow-up. Sensitivity of screening protocols can be adjusted by including lengthier screener assessments (e.g., self-report C-SSRS-SV instead of single item PHQ-9 screener), particularly for studies enrolling at-risk Veterans. For review of common SRAM adaptations for online and EMA studies, see Bai et al. (2021) . Nontraditional Research Settings Occasionally, studies involve administration of study procedures outside traditional research settings, such as healthcare or community settings. Translation of SRAMs to these settings necessitate adaption. For example, research within healthcare settings typically relies on close coordination between researchers and provider(s) and therefore often benefits from coordinated implementation of SRAM, particularly ongoing risk monitoring (see Coordination with Existing Providers ). Research conducted in community settings requires additional consideration of cultural norms, confidentiality concerns, and stigma. Within these settings, Veterans commonly view researchers as “outsiders” with little understanding of and respect for community norms, and participants are often reticent to disclose details that are stigmatized and/or perceived to have potential career implications, including those related to suicide ( DeVoe et al., 2012 ). To promote engagement of community Veterans in research SRAM, researchers are transparent about the nature and purpose of SRAM, tie use of SRAM to broader Veteran cultural values, directly involve community members in adapting SRAMs, and integrate trusted, community-based resources and programming into risk management strategies (e.g., churches, peers, Veteran Service Organizations). These strategies allow Veterans to feel a part of SRAM efforts and for SRAM procedures to align with community values, norms, and inherent strengths and resources. ADDITIONAL CONSIDERATIONS Local Regulations Researchers and study staff must be aware of local civil commitment and duty-to-warn/protect requirements. Particularly when working with participants virtually, these requirements can vary significantly according to participant physical location. When conditions require researcher(s) to break confidentiality, researchers maintain, as feasible, a collaborative, transparent, and supportive approach. Ensuring collaboration throughout reporting procedures maximizes likelihood of participants experiencing disclosure as positive, thereby promoting healthy future disclosure ( Ammerman et al., 2021 ). Potential Iatrogenic Effects of Suicide Risk Assessment Some researchers and IRBs may be hesitant to pursue suicide-focused research due to fear of potential iatrogenic effects ( Hom et al., 2017 ). However, these parties should be assured by the wealth of literature attesting no evidence for iatrogenic effects of suicide risk assessment or intensive suicide-focused research protocols both generally ( Blades et al., 2018 ; DeCou & Schumann, 2018 ) and with Veteran samples ( Poindexter et al., 2019 ). Recent meta-analyses suggest suicide risk assessment yields nonsignificant or even favorable effects on suicidal ideation and suicide-related behaviors, even in high-risk and vulnerable study populations ( Blades et al., 2018 ; DeCou & Schumann, 2018 ). In other words, avoiding asking about suicide does not influence whether risk exists; it only limits opportunity to mitigate risk among potentially at-risk participants. Ignorance of suicide risk through avoidance of adequate risk assessment is irresponsible, particularly in research with Veterans given their comparatively higher risk relative to civilians. Fear surrounding potential consequences of suicide risk assessment should never be used to justify lack of integrating adequate SRAMs into research protocols. Accordingly, SPRINT advises against exclusion of potential research participants from studies due to elevated suicide risk, because doing so directly limits empirical understandings of suicide risk ( VA, 2022 ). Promoting a Culture that Prioritizes SRAM Particularly for researchers and research protocols that are not suicide-focused, SRAMs can feel like a significant deviation from broader study protocols. Ensuring consistent implementation of SRAMs therefore requires promoting an institutional culture that prioritizes SRAM. Strategies to promote this culture include (a) routine training of staff on SRAMs, (b) explicitly tying SRAMs to broader departmental values and goals, (c) highlighting results of suicide risk assessments (e.g., prevalence of participant suicide risk indicators) within departmental meetings, and (d) promoting collaboration and/or consultation with suicide researchers throughout study design and execution, particularly in studies sampling potentially high-risk populations (e.g., individuals with medical illnesses, severe mental illnesses). Managing Participant Suicide Inevitably, research teams working with at-risk populations will experience a participant suicide. Local IRBs and regulations will determine official reporting and documentation requirements for such events. However, teams should also debrief internally to ensure members have adequate support and training necessary to effectively cope with emotional reactions to participant deaths. The research relationship is unique in that (a) it is highly structured and time-limited, (b) researchers are ethically responsible for participant health and wellbeing, at least temporarily, and (c) researchers may become significantly emotionally engaged and/or invested in the participant’s wellbeing (necessary for building empathic rapport) yet nonetheless removed from participant lives. Researchers investigating sensitive topics (e.g., illness, dying, trauma) commonly describe experiencing significant emotional fatigue, psychological and physiological distress, and burnout because of data collection and analysis ( Burles, 2017 ; Woodby et al., 2011 ). Research relationships with potentially at-risk participants therefore places researchers in a vulnerable position when learning about participant suicide-related deaths. Deaths may occur within or outside research contexts (e.g., a participant of an ongoing clinical trial dies by suicide; a researcher sees an obituary for a former research participant). Regardless of context, researchers may face a range of emotional reactions, including sadness, grief, denial, helplessness, guilt, and anxiety, and these reactions may be amplified while navigating IRB reporting and documentation requirements. Posttraumatic and/or complicated grief reactions may also occur, with significant implications on later mental health, occupational functioning, and social adjustment ( Dransart et al., 2019 ). Social support plays a key role in mitigating detrimental influences of suicide bereavement ( Scott et al., 2020 ). Research teams experiencing participant suicide should therefore be offered targeted postvention support that emphasizes connection to quality social supports. CONCLUSIONS United States military Veterans face significantly greater rates of suicide-related behaviors and death than their civilian peers. Accordingly, effective prevention of Veteran suicide and mitigation of Veteran suicide risk have been named top VA clinical priorities. In service of these priorities, VA researchers pursue a wealth of suicide-focused research. SRAMs serve to identify Veteran participants at risk for suicide; clarify their risk; connect at-risk participants to safety-promoting supports; and maximize collaboration between researchers and participants throughout SRAM. SRAM is an ongoing process. It requires nuanced understanding of suicide risk as a fluid construct in constant flux and therefore requiring corresponding flexibility in risk management. The current manuscript offers a standardized and operational approach to Veteran-focused SRAM to improve ongoing and future Veteran suicide research. Supplementary Material Supplemental Figure NIHMS2057358-supplement-Supplemental_Figure.docx (29KB, docx) Acknowledgements: Work for this article was supported by funding from the Department of Veterans Affairs, Rehabilitation Research & Development Service to Dr. Edwards (1I01RX004566–01A1) and the VISN-2 MIRECC. Dr. Hazlett receives support from a VA CSR&D Senior Research Career Scientist Award (IK6 CX002700) Footnotes 1 Note: This section includes a brief discussion of common adaptations to SRAMs. It is not intended to represent a comprehensive list of possible adaptations. Disclosure : The views expressed here are the authors’ and do not necessarily represent the views of the Department of Veterans Affairs. References Ægisdóttir S, White MJ, Spengler PM, Maugherman AS, Anderson LA, Cook RS, ... & Rush JD. (2006). The meta-analysis of clinical judgment project: Fifty-six years of accumulated research on clinical versus statistical prediction. The Counseling Psychologist, 34(3), 341–382. 10.1177/0011000005285875 [ DOI ] [ Google Scholar ] Akther SF, Molyneaux E, Stuart R, Johnson S, Simpson A, & Oram S (2019). Patients’ experiences of assessment and detention under mental health legislation: Systematic review and qualitative meta-synthesis. BJPsych Open, 5(3), e37. 10.1192/bjo.2019.19 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Ammerman BA, Carter SP, Gebhardt HM, Buchholz J, & Reger MA (2021). An initial investigation of suicide attempt disclosures among US veterans. Crisis, 42(6), 411–417. 10.1027/0227-5910/a000727 [ DOI ] [ PubMed ] [ Google Scholar ] Ammerman BA, Piccirillo ML, O’Loughlin CM, Carter SP, Matarazzo B, & May AM (2022). The role of suicide stigma in self-disclosure among civilian and veteran populations. Psychiatry Research, 309, 114408. 10.1016/j.psychres.2022.114408 [ DOI ] [ PubMed ] [ Google Scholar ] Bai S, Babeva KN, Kim MI, & Asarnow JR (2021). Future directions for optimizing clinical science & safety: Ecological momentary assessments in suicide/self-harm research. Journal of Clinical Child & Adolescent Psychology, 50(1), 141–153. 10.1080/15374416.2020.1815208 [ DOI ] [ PubMed ] [ Google Scholar ] Barzilay S, Yaseen ZS, Hawes M, Kopeykina I, Ardalan F, Rosenfield P, ... & Galynker I. (2019). Determinants and predictive value of clinician assessment of short-term suicide risk. Suicide and Life-Threatening Behavior, 49(2), 614–626. 10.1111/sltb.12462 [ DOI ] [ PubMed ] [ Google Scholar ] Berman NC, Stark A, Cooperman A, Wilhelm S, & Cohen IG (2015). Effect of patient and therapist factors on suicide risk assessment. Death Studies, 39(7), 433–441. 10.1080/07481187.2014.958630 [ DOI ] [ PubMed ] [ Google Scholar ] Blades CA, Stritzke WGK, Page AC, & Brown JD (2018). The benefits and risks of asking research participants about suicide: A meta-analysis of the impact of exposure to suicide-related content. Clinical Psychology Review, 64, 1–12. 10.1016/j.cpr.2018.07.001 [ DOI ] [ PubMed ] [ Google Scholar ] Britton PC, Karras E, Stecker T, Klein J, Crasta D, Brenner LA, & Pigeon WR (2022). Veterans crisis line call outcomes: Distress, suicidal ideation, and suicidal urgency. American Journal of Preventive Medicine, 62(5), 745–751. 10.1016/j.amepre.2021.11.013 [ DOI ] [ PubMed ] [ Google Scholar ] Burles MC (2017). Negotiating post-research encounters: Reflections on learning of participant deaths following a qualitative study. Mortality, 22(2), 170–180. 10.1080/13576275.2017.1291605 [ DOI ] [ Google Scholar ] Campbell SB, Gray KE, Hoerster KD, Fortney JC, & Simpson TL (2021). Differences in functional and structural social support among female and male veterans and civilians. Social Psychiatry and Psychiatric Epidemiology, 56(3), 375–386. 10.1007/s00127-020-01862-4 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Danzer G, & Wilkus-Stone A (2015). The give and take of freedom: The role of involuntary hospitalization and treatment in recovery from mental illness. Bulletin of the Menninger Clinic, 79(3), 255–280. 10.1521/bumc.2015.79.3.255 [ DOI ] [ PubMed ] [ Google Scholar ] DeCou CR, & Schumann ME (2018). On the iatrogenic risk of assessing suicidality: A meta-analysis. Suicide and Life-Threatening Behavior, 48(5), 531–543. 10.1111/sltb.12368 [ DOI ] [ PubMed ] [ Google Scholar ] DeVoe ER, Ross AM, & Paris R (2012). Build it together and they will come: The case for community-based participatory research with military populations. Advances in Social Work, 13(1), 149–165. 10.18060/1888 [ DOI ] [ Google Scholar ] Department of Veterans Affairs. (2022). Risk Management Resources for Working with VA Research Participants. Office of Health Services Research & Development. https://www.hsrd.research.va.gov/centers/core/sprint/risk_management/ . [ Google Scholar ] Department of Veterans Affairs. (2023a). National Veteran suicide prevention annual report. Office of Mental Health and Suicide Prevention. https://www.mentalhealth.va.gov/docs/data-sheets/2023/2023-National-Veteran-Suicide-Prevention-Annual-Report-FINAL-508.pdf . [ Google Scholar ] Department of Veterans Affairs. (2023b). The President’s 2023 budget. https://www.govinfo.gov/content/pkg/BUDGET-2023-BUD/pdf/BUDGET-2023-BUD-19.pdf . Department of Veterans Affairs (2024a). Office of Research & Development request for applications (RFA) and program announcements. https://www.research.va.gov/funding/rfa.cfm Department of Veterans Affairs & Department of Defense. (2024). VA/DoD Clinical Practice Guideline for the Assessment and Management of Suicide Risk. Washington, DC. Retrieved from https://www.healthquality.va.gov/guidelines/MH/srb/VADoD-CPG-Suicide-Risk-Full-CPG-2024_Final_508.pdf [ Google Scholar ] Dransart DAC, Treven M, Grad OT, & Andriessen K (2017). Impact of client suicide on health and mental health professionals. In Andriessen K, Krysinska K, & Grad OT (Eds.), Postvention in action: The international handbook of suicide bereavement support (pp. 245–254). Hogrefe. [ Google Scholar ] Doran N, Bismark A, Khalifian C, Mishra J, De Peralta S, & Martis B (2021). Associations between veteran encounters with suicide prevention team and suicide-related outcomes. Suicide and Life-Threatening Behavior, 51(4), 729–735. 10.1111/sltb.12760 [ DOI ] [ PubMed ] [ Google Scholar ] Edwards ER, Epshteyn G, Snyder S, Gorman D, Coolidge B, Marcano E, ... & Goodman M. (2023a). Dialectical Behavior Therapy for Justice-Involved Veterans: Changes in treatment targets in a small, pre-post design clinical trial. Psychological Services, 20(Suppl 2), 98–107. 10.1037/ser0000766 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Edwards ER, Goldsmith MM, Tran HN, Bulanchuk NK, Epshteyn G, Wrobleski J, ... & Geraci JC. (2023b). Supporting the nation’s transitioning veterans: Narrative review of practices and recommendations for psychotherapy and counseling of veterans separating from military service. Psychological Services, 20(4), 876–888. 10.1037/ser0000701 [ DOI ] [ PubMed ] [ Google Scholar ] Ferguson M, Rhodes K, Loughhead M, McIntyre H, & Procter N (2022). The effectiveness of the safety planning intervention for adults experiencing suicide-related distress: A systematic review. Archives of Suicide Research, 26(3), 1022–1045. 10.1080/13811118.2021.1915217 [ DOI ] [ PubMed ] [ Google Scholar ] Gamarra JM, Luciano MT, Gradus JL, & Wiltsey Stirman S (2015). Assessing variability and implementation fidelity of suicide prevention safety planning in a regional VA Healthcare System. Crisis, 36(6), 433–439. 10.1027/0227-5910/a000345 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Green JD, Kearns JC, Rosen RC, Keane TM, & Marx BP (2018). Evaluating the effectiveness of safety plans for military veterans: Do safety plans tailored to veteran characteristics decrease suicide risk? Behavior Therapy, 49(6), 931–938. 10.1016/j.beth.2017.11.005 [ DOI ] [ PubMed ] [ Google Scholar ] Gujral K, Bahraini N, Brenner LA, Campen JV, Zulman DM, Illarmo S, & Wagner TH (2023). VA’s implementation of universal screening and evaluation for the suicide risk identification program in November 2020 –Implications for Veterans with prior mental health needs. PLOS ONE, 18(4), e0283633. 10.1371/journal.pone.0283633 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Hom MA, Podlogar MC, Stanley IH, & Joiner TE (2017). Ethical issues and practical challenges in suicide research. Crisis, 38(2), 107–114. 10.1027/0227-5910/a000415 [ DOI ] [ PubMed ] [ Google Scholar ] Hoyt T, Holliday R, Simonetti JA, & Monteith LL (2021). Firearm lethal means safety with military personnel and veterans: Overcoming barriers using a collaborative approach. Professional Psychology: Research and Practice, 52(4), 387–395. 10.1037/pro0000372 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Huggett C, Gooding P, Haddock G, Quigley J, & Pratt D (2022). The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clinical Psychology & Psychotherapy, 29(4), 1203–1235. 10.1002/cpp.2726 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Johnson LL, Muehler T, & Stacy MA (2021). Veterans’ satisfaction and perspectives on helpfulness of the Veterans Crisis Line. Suicide and Life-Threatening Behavior, 51(2), 263–273. 10.1111/sltb.12702 [ DOI ] [ PubMed ] [ Google Scholar ] Katz I, Barry CN, Cooper SA, Kasprow WJ, & Hoff RA (2020). Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) in a large sample of veterans receiving mental health services in the Veterans Health Administration. Suicide and Life-Threatening Behavior, 50(1), 111–121. 10.1111/sltb.12584 [ DOI ] [ PubMed ] [ Google Scholar ] Kivelä L, van der Does WAJ, Riese H, & Antypa N (2022). Don’t miss the moment: A systematic review of ecological momentary assessment in suicide research. Frontiers in Digital Health, 4. https://www.frontiersin.org/articles/10.3389/fdgth.2022.876595 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Koenig CJ, Maguen S, Daley A, Cohen G, & Seal KH (2013). Passing the baton: A grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings. Journal of General Internal Medicine, 28, 41–50. 10.1007/s11606-012-2167-5 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Kroenke K, Spitzer RL, & Williams JBW (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613. 10.1046/j.1525-1497.2001.016009606.x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Lehavot K, Hoerster KD, Nelson KM, Jakupcak M, & Simpson TL (2012). Health indicators for military, veteran, and civilian women. American Journal of Preventive Medicine, 42(5), 473–480. 10.1016/j.amepre.2012.01.006 [ DOI ] [ PubMed ] [ Google Scholar ] Lehavot K, Katon JG, Chen JA, Fortney JC, & Simpson TL (2018). Post-traumatic stress disorder by gender and veteran status. American Journal of Preventive Medicine, 54(1), e1–e9. 10.1016/j.amepre.2017.09.008 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Louzon SA, Bossarte R, McCarthy JF, & Katz IR (2016). Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatric Services, 67(5), 517–522. 10.1176/appi.ps.201500149 [ DOI ] [ PubMed ] [ Google Scholar ] Luxton DD, O’Brien K, Pruitt LD, Johnson K, & Kramer G (2014). Suicide risk management during clinical telepractice. The International Journal of Psychiatry in Medicine, 48(1), 19–31. 10.2190/PM.48.1.c [ DOI ] [ PubMed ] [ Google Scholar ] Matarazzo BB, Brown GK, Stanley B, Forster JE, Billera M, Currier GW, ... & Brenner LA. (2019). Predictive validity of the Columbia-Suicide Severity Rating Scale among a cohort of at-risk veterans. Suicide and Life-Threatening Behavior, 49(5), 1255–1265. 10.1111/sltb.12515 [ DOI ] [ PubMed ] [ Google Scholar ] Matarazzo BB, Eagan A, Landes SJ, Mina LK, Clark K, Gerard GR, ... & Reger MA. (2023). The Veterans Health Administration REACH VET program: Duicide predictive modeling in practice. Psychiatric Services, 74(2), 206–209. 10.1176/appi.ps.202100629 [ DOI ] [ PubMed ] [ Google Scholar ] Michaels MS, Chu C, Silva C, Schulman BE, & Joiner T (2015). Considerations regarding online methods for suicide-related research and suicide risk assessment. Suicide and Life-Threatening Behavior, 45(1), 10–17. 10.1111/sltb.12105 [ DOI ] [ PubMed ] [ Google Scholar ] Monteith LL, Wendleton L, Bahraini NH, Matarazzo BB, Brimner G, & Mohatt NV (2020). Together with veterans: VA national strategy alignment and lessons learned from community-based suicide prevention for rural veterans. Suicide and Life-Threatening Behavior, 50(3), 588–600. 10.1111/sltb.12613 [ DOI ] [ PubMed ] [ Google Scholar ] Newton-Howes G, & Mullen R (2011). Coercion in psychiatric care: Systematic review of correlates and themes. Psychiatric Services, 62(5), 465–470. 10.1176/ps.62.5.pss6205_0465 [ DOI ] [ PubMed ] [ Google Scholar ] Poindexter EK, Nazem S, Barnes SM, Hostetter TA, & Smith PN (2019). Veteran participation in intensive suicide research protocols: No evidence of iatrogenic effects. Suicide and Life-Threatening Behavior, 49(1), 303–309. 10.1111/sltb.12444 [ DOI ] [ PubMed ] [ Google Scholar ] Posner K, Brent D, Lucas C, Gould M, Stanley B, Brown G, ... & Mann J. (2008). Columbia-Suicide Severity Rating Scale (C-SSRS). New York: Research Foundation for Mental Hygiene. [ Google Scholar ] Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, ... Mann JJ (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. The American Journal of Psychiatry, 168(12), 1266–1277. 10.1176/appi.ajp.2011.10111704 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Pruitt LD, Sung JC, & Walker KA (2022). What is “safety”?: Lethal means counseling as a cross-cultural communication. Military Psychology, 34(3), 352–365. 10.1080/08995605.2022.2040939 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Schatten HT, Gaudiano BA, Primack JM, Arias SA, Armey MF, Miller IW, ... & Weinstock LM. (2020). Monitoring, assessing, and responding to suicide risk in clinical research. Journal of Abnormal Psychology, 129(1), 64–69. 10.1037/abn0000489 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Scott HR, Pitman A, Kozhuharova P, & Lloyd-Evans B (2020). A systematic review of studies describing the influence of informal social support on psychological wellbeing in people bereaved by sudden or violent causes of death. BMC Psychiatry, 20(1), 265. 10.1186/s12888-020-02639-4 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Sharp ML, Fear NT, Rona RJ, Wessely S, Greenberg N, Jones N, & Goodwin L (2015). Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiologic Reviews, 37(1), 144–162. 10.1093/epirev/mxu012 [ DOI ] [ PubMed ] [ Google Scholar ] Spitzer EG, Stearns-Yoder KA, Hoffberg AS, Bailey HM, Miller CJ, & Simonetti JA (2024). A systematic review of lethal means safety counseling interventions: Impacts on safety behaviors and self-directed violence. Epidemiologic Reviews, mxae001. 10.1093/epirev/mxae001 [ DOI ] [ PubMed ] [ Google Scholar ] Stanley B, & Brown GK (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. 10.1016/j.cbpra.2011.01.001 [ DOI ] [ Google Scholar ] Stevens K, Thambinathan V, Hollenberg E, Inglis F, Johnson A, Levinson A, ... & Cleverley K. (2021). Core components and strategies for suicide and risk management protocols in mental health research: A scoping review. BMC Psychiatry, 21(13), 1–14. 10.1186/s12888-020-03005-0 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] The Joint Commission. (2018). National patient safety goal for suicide prevention. https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/ [ DOI ] [ PubMed ] Theis J, Hoops K, Booty M, Nestadt P, & Crifasi C (2021). Firearm suicide among veterans of the U.S. military: A systematic review. Military Medicine, 186(5–6), e525–e536. 10.1093/milmed/usaa495 [ DOI ] [ PubMed ] [ Google Scholar ] Ward-Ciesielski EF, & Wilks CR (2020). Conducting research with individuals at risk for suicide: Protocol for assessment and risk management. Suicide and Life-Threatening Behavior, 50(2), 461–471. 10.1111/Fsltb.12602 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Weinstock LM, Bishop TM, Bauer MS, Benware J, Bossarte RM, Bradley J, ... & Kessler RC. (2024). Design of a multicenter randomized controlled trial of a post-discharge suicide prevention intervention for high-risk psychiatric inpatients: The Veterans Coordinated Community Care Study. Internal Journal of Methods in Psychiatric Research, 33(4), e70003. 10.1002/mpr.70003 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Woodby LL, Williams BR, Wittich AR, & Burgio KL (2011). Expanding the notion of researcher distress: The cumulative effects of coding. Qualitative Health Research, 21(6), 830–838. 10.1177/1049732311402095 [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. 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