Group-Based Suicide Safety Planning and Skills Training for Veterans With High Suicide Risk: A Randomized Clinical Trial.

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Learn more: PMC Disclaimer | PMC Copyright Notice JAMA Netw Open . 2026 May 29;9(5):e2615029. doi: 10.1001/jamanetworkopen.2026.15029 Group-Based Suicide Safety Planning and Skills Training for Veterans With High Suicide Risk A Randomized Clinical Trial Marianne Goodman 1, 2, ✉ , Shari Jager-Hyman 3 , Maureen Monahan 4, 5 , Sofie Glatt 1 , Michael E Thase 3, 6 , Shiela O’Brien 7 , Alison Krauss 7 , Hanga C Galfalvy 4, 5 , Sarah R Sullivan 8 , James Luther 9, 10 , Gregory K Brown 3 Author information Article notes Copyright and License information 1 Veterans Integrated Service Network (VISN) 2 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters Veterans Affairs Medical Center, Bronx, New York 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York 3 Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia 4 New York State Psychiatric Institute, New York 5 Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York 6 Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania 7 Central Texas Veterans Health Care System, Waco 8 Department of Psychology, Hunter College and the City University of New York Graduate Center, City University of New York, New York 9 Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania 10 VISN 5 MIRECC, Pittsburgh Veterans Affairs Medical Center, Pittsburgh, Pennsylvania Accepted for Publication: April 4, 2026. Published: May 29, 2026. doi: 10.1001/jamanetworkopen.2026.15029 Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2026 Goodman M et al. JAMA Network Open . ✉ Corresponding Author: Marianne Goodman, MD, James J. Peters Veterans Affairs Medical Center, 130 W Kingsbridge Rd, Bronx, NY 10468 ( Marianne.goodman@va.gov ). Author Contributions: Dr Goodman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Goodman, Thase, Brown. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Goodman, Jager-Hyman, Monahan, Glatt, Brown. Critical review of the manuscript for important intellectual content: All authors. Statistical analysis: Glatt, Galfalvy, Luther. Obtained funding: Goodman. Administrative, technical, or material support: Goodman, Thase, O’Brien, Krauss, Sullivan, Brown. Supervision: Goodman, Thase. Competence and adherence assessment : Monahan. Conflict of Interest Disclosures: Dr Goodman reported receiving grants from the Veterans Affairs (VA) Office of Research and Development during the conduct of the study; grants from the American Foundation for Suicide Prevention, USAA Face The Fight, and the VA Office of Suicide Prevention outside the submitted work; and personal fees from Boehringer Ingelheim Pharmaceuticals and the New York State Psychiatric Association outside the submitted work. Dr Jager-Hyman reported receiving grants from the US Department of Veterans Affairs and the National Institutes of Health during the conduct of the study. Dr Monahan reported receiving grants from US Department of Veterans Affairs during the conduct of the study. Dr Thase reported no conflicting interests associated with this work. With respect to unrelated outside interests, Dr Thase reported receiving support from research grants from Acadia Inc, Alkermes, Atai, Axsome Therapeutics Inc, Johnson & Johnson (Intracellular Inc and Janssen Pharmaceuticals Inc), Myriad, National Institute of Mental Health, Otsuka Pharmaceutical Company Ltd, Patient Centered Outcomes Research Institute (PCORI), and Takeda Pharmaceutical Company Ltd. Dr Thase reported advisory or consulting work with AbbVie Pharmaceuticals, Autobahn Therapeutics, Axsome Therapeutics Inc, Gerson Lehman, GH Therapeutics, H. Lundbeck A/S, Janssen Pharmaceuticals Inc, Johnson & Johnson (Intracellular and Janssen), Luye Pharma Group Ltd, Merck & Company Inc, Otsuka Pharmaceutical Company Ltd, Pfizer Inc, Sage Pharmaceuticals, and Takeda Pharmaceutical Company Ltd. Dr Thase reported receiving royalties from the American Psychiatric Foundation, Guilford Publications, Herald House, Kluwer-Wolters, and W.W. Norton & Company Inc. In addition, Dr Thase reported that his spouse is Senior Vice President of Open Health, which does business with most major pharmaceutical companies. Dr O’Brien reported receiving grants from US Department of Veterans Affairs during the conduct of the study. Dr Galfalvy reported receiving grants from the National Institute of Mental Health (NIMH), American Foundation for Suicide Prevention (AFSP), VA, and PCORI outside the submitted work and other fees from James Peters VA Medical Center during the conduct of the study. Dr Brown reported receiving royalties from the Research Foundation for Mental Hygiene Inc for the commercial use of the Columbia Suicide Severity Rating Scale and research grants from the AFSP, USAA Face the Fight, NIMH, and the VA. No other disclosures were reported. Funding/Support: This submission presents a primary analysis of research that was supported by the US Department of Veterans Affairs under award number I01 CX001705-01A1 (Dr Goodman). Dr Goodman and Ms Glatt were supported by the Veterans Integrated Service Network (VISN) 2 Mental Illness Research, Education, and Clinical Center (MIRECC). Drs O’Brien and Krauss were supported by funding from the US Department of Veterans Affairs, Office of Research Development and the VISN 17 Center of Excellence. Dr Thase was supported by funding from the VISN 5 MIRECC. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed here are the authors’ and do not necessarily represent the views of the VA. Data Sharing Statement: See Supplement 3 . Additional Contributions: We want to thank the veterans who participated in our trial and our team of paid research coordinators including from the James J. Peters site: Caroline Boucher, MSW; Lakshmi Chennapragada, MA; Emilia Fonseca, BS; Kyra Hamerling-Potts, BS; Emily Mitchell, BA; Terra Osterberg, BA; Angela Page Spears, BS; Madison Strouse, BA; and from the Philadelphia VA site: Darlene Hodge-Rodriquez, BA; Michelle Gordon, MPH; and Emilie Kipp, LCPC, MS. We also acknowledge the contributions of co-investigator Barbara Stanley, PhD from Columbia University before her untimely death. ✉ Corresponding author. Received 2025 Nov 21; Accepted 2026 Apr 4; Collection date 2026 May. Copyright 2026 Goodman M et al. JAMA Network Open . This is an open access article distributed under the terms of the CC-BY License. PMC Copyright notice PMCID: PMC13221691  PMID: 42213437 Key Points Question Does Project Life Force (PLF), a manualized suicide safety planning group intervention augmented with skills training, reduce suicidal behavior among veterans at high risk for suicide over 12 months? Findings In this randomized clinical trial of 207 veterans at high risk for suicide, no difference was found in time to first suicidal behavior between participants in the PLF arm compared with those in the treatment as usual (TAU) arm. However, PLF participants demonstrated a significantly lower number of actual attempts and improved suicide-related coping than TAU participants. Meaning These findings suggest that PLF may lower suicide risk among veterans at high risk for suicide. This randomized clinical trial evaluates Project Life Force, a group-based suicide safety planning and skills training intervention for veterans at high risk for suicide, comparing its effects to standard treatment over a 12-month period. Abstract Importance Novel evidence-based suicide-specific treatments are critical to addressing rising rates of suicide among veterans. Objective To determine whether Project Life Force (PLF), a group intervention that augments suicide safety planning (SSP) with skills training, plus treatment as usual (TAU) delays or decreases suicidal behavior compared with TAU alone. Design, Setting, and Participants This multisite randomized clinical trial, using intention-to-treat analyses, included veterans at high risk for suicide. Participants were recruited after psychiatric inpatient discharge or referral from 4 Veterans Health Administration outpatient care teams in hospitals in Pennsylvania, New York, and Texas between March 2018 and February 2024. Data were analyzed from April 2024 to October 2025. Intervention PLF is a manualized, 10- to 12-session (75-90 minutes per session) group intervention combining SSP with distress tolerance, emotion regulation, and interpersonal skills training. Sessions cover each of the 6 SSP steps, health management, reasons for living, SSP accessibility, and a recap, with up to 4 optional booster sessions offered. All participants received TAU, constituting individual SSP and standard outpatient mental health care. Main Outcomes and Measures The primary outcome was time in days to first suicidal behavior (aborted, interrupted, or actual attempts or suicide death) over 12 months, assessed using the Columbia Suicide Severity Rating Scale and chart review. Secondary outcomes over 12 months included self-report measures of hopelessness, depression, treatment use, attitudes toward help-seeking, and suicide-related coping. Results A total of 207 participants (mean [SD] age, 46.1 [13.9] years; 178 male [86%]) were assessed at baseline and randomly assigned to PLF plus TAU (101 participants) or TAU alone (106 participants). Cox proportional hazards models showed no significant between-group difference in time to suicidal behavior; however, compared with TAU, PLF participants had a lower hazard of actual suicide attempts over 1 year (HR, 0.49; 95% CI, 0.26-0.92; P = .03). Secondary outcome analyses included data from 132 participants (64%) at posttreatment, 125 (60%) at month 6, and 130 (62%) at month 12. Treatment-by-time effects ranged from Cohen d = −0.03 to 0.35. Notably, PLF significantly improved suicide-related coping at posttreatment (estimate, 4.06; Cohen d , 0.21; P = .04) and month 6 (estimate, 5.36; Cohen d , 0.27; P = .007). No study-related adverse events occurred. Conclusions and Relevance In this randomized clinical trial of 207 participants, PLF plus TAU did not change time to suicidal behavior but did increase time to actual suicide attempts and improve suicide-related coping, thereby enhancing SSP impact. Trial Registration ClinicalTrials.gov Identifier: NCT03653637 Introduction Compared with civilians, US veterans have more than twice the age- and sex- adjusted suicide rate and account for about 15% of suicide deaths. 1 Despite suicide prevention being a top clinical priority for the US Department of Veterans Affairs (VA), more than 6400 veterans died by suicide in 2022. 1 One component of VA’s suicide prevention efforts mandates that clinicians develop with every patient at high risk a Suicide Safety Plan (SSP) to mitigate short-term suicide risk. 2 , 3 Safety planning is strongly recommended by several government agencies 4 , 5 and associated with improvements in suicidal symptoms, depression, hopelessness, treatment engagement and hospitalization rates. 6 However, significant obstacles limit the usefulness of SSPs, 7 including limited clinician follow-up after SSP development 8 and inadequate skills and/or support networks necessary to optimize SSP implementation. 9 To address these gaps, we created Project Life Force (PLF), a novel group intervention that leverages social interaction and skills training to maximize SSP engagement and effectiveness. 10 , 11 PLF is a manualized 10-session group intervention wherein veterans revise their SSPs while learning distress tolerance, emotion regulation, and interpersonal skills necessary for effective implementation (trial protocol in Supplement 1 ). 10 , 11 PLF uses a group format to mitigate loneliness and foster belongingness, both key risk factors for suicide. 12 , 13 Advantages of group therapy for veterans at high risk for suicide include cost-effectiveness; use of peer support, which has an emerging evidence base for suicide prevention 14 ; and congruency with military cultural values of teamwork and camaraderie. 15 PLF differs from many skill-based group treatments as suicidality is directly discussed to emphasize the application of coping skills and management. Discussion of shared experiences and reciprocal support cultivates connection, belongingness, and self-efficacy. After our open-label PLF study that demonstrated improvements in suicidal symptom severity, depression, and hopelessness, 11 we conducted the current multisite RCT and now report on our first 2 aims described in our protocol paper 10 and clinical trial registration. Our objective was to compare the impact of PLF plus TAU (henceforth referred to as PLF) with TAU on suicide behavior and associated suicide risk factors, including hopelessness and depression, as well as protective factors including mental health care use and suicide-related coping (SRC). We also explored a potential mediator of PLF, thwarted belongingness, based on the interpersonal theory of suicide. 12 , 13 We hypothesized that, relative to TAU, PLF would (1) increase the time to suicide behavior, (2) decrease depression and hopelessness, (3) increase positive attitudes toward mental health treatment and improve engagement, (4) increase SRC, and (5) decrease thwarted belongingness. Methods Study Design This RCT was conducted at 4 VA Medical Centers (VAMCs): James J. Peters VAMC (Bronx, New York; n = 129), Corporal Michael J. Crescenz VAMC (Philadelphia, Pennsylvania; n = 59), Central Texas Veterans Health Care System (Waco, Texas; n = 17), and Northport VAMC (Northport, New York; n = 2). Study procedures were reviewed and approved by each VAMC’s Institutional Review Board and Research and Development Office. The study was registered at ClinicalTrials.gov and adheres to the Consolidated Standards of Reporting Trials ( CONSORT ) reporting guidelines. Participants and Procedures A total of 294 veterans at high risk for suicide provided written informed consent after a suicide-related hospitalization or referral from an outpatient clinic. Among these individuals, 207 were randomized to either PLF or TAU using a computerized block randomization stratified by suicide attempt history (yes or no). All randomized participants were included in analyses consistent with the intention-to-treat (ITT) principle. Inclusion and exclusion criteria are detailed elsewhere. 10 Assessments were collected at baseline, posttreatment (month 3), 3 months posttreatment (month 6), and 6 months posttreatment (month 12). Figure 1 presents a CONSORT flow diagram. Figure 1. CONSORT Flow Diagram. Open in a new tab Treatment Conditions TAU TAU was operationalized as current standard of care for individuals with suicidal thoughts or behavior who were discharged from an inpatient unit or flagged for high risk for suicide, including individualized safety planning. The only methodological difference between conditions is that PLF participants also attended the PLF group sessions to augment their SSPs. PLF PLF is a manualized 10-week group treatment with weekly 90-minute sessions. Session content is described in Goodman et al. 10 In this RCT, PLF was cofacilitated by 2 licensed mental health clinicians and included 4 to 6 veterans. After completing the PLF curriculum, veterans were offered optional booster sessions (n = 4). Fidelity Monitoring Independent PLF experts assessed fidelity by rating a random selection (20%) of session recordings using the PLF Adherence and Competence Monitoring Rating Form, developed for the study. The form evaluates general clinical competence and session-specific PLF components on a scale of 0 to 3 points. Adherence was 94% for general competency and 90% for session-specific adherence averaged across sites. Protocol Modifications This RCT, conducted from March 2018 to February 2024, was affected by the COVID-19 pandemic, necessitating protocol modifications affecting participants (n = 119; 58 TAU and 61 PLF). After March 2020, PLF moved from in-person to virtual delivery, although session content did not change. Modifications necessary for virtual PLF included having a communication coordinator who supported virtual logistics and developing virtual safety protocols. Additionally, a prespecified exploratory aim assessing SSP quality was not completed due to difficulties obtaining revised SSPs with the transition to virtual care. Measures Primary Outcome: Time to Suicide Behavior Suicide behavior was operationalized as a composite outcome defined as any occurrence of suicide behavior (actual, interrupted, or aborted suicide attempt or suicide death) ascertained from 3 sources (self-report, record review, and death registry) during the 12-month follow-up period. First, the Columbia Suicide Severity Rating Scale, 16 the gold standard for suicide assessment, 17 was administered at every study visit. Using the behavior subscale, we defined presence of suicide behavior, in part, as an affirmative response for any actual, aborted, or interrupted attempt. We randomly selected 20% of C-SSRS recordings to assess interrater reliability, with adequate intraclass correlations ranging from 0.87 to 0.93 across sites. Second, we extracted instances of suicide behavior from patient charts for all participants who missed study assessments. Third, to measure suicide behavior that included suicide deaths for participants who were lost to follow-up, in addition to examining VA medical records, we performed internet searches, queried state vital statistics registries, and reviewed death certificates as needed. Secondary and Exploratory Outcomes Depression was assessed using the Beck Depression Inventory-II. 18 Hopelessness was measured using the Beck Hopelessness Scale, 19 with additional separate sum scores for negative and positive expectations. 20 Mental health treatment engagement was determined using chart reviews to quantify the sum of outpatient mental health treatment visits for 6 months, excluding PLF sessions. During the pandemic, this included telephone and virtual sessions. Attitudes toward seeking professional help for psychological disturbance was measured by the Attitudes Toward Seeking Professional Psychological Help Scale–Short Form. 21 , 22 We used the Suicide-Related Coping Scale (SRCS) 23 to measure knowledge of, and perceived confidence in using, internal coping strategies and external supports to regulate suicidal thoughts and urges. We calculated a total SRCS score, as well as external and internal coping subscales. The exploratory outcome of thwarted belongingness was assessed with the Interpersonal Needs Questionnaire (INQ)-15. 13 Diagnostic and Descriptive Measures We assessed lifetime and current psychiatric disorders using The Mini-International Neuropsychiatric Interview. 24 Monitoring and oversight of the diagnostic assessment was performed by investigators from Columbia University. Past-year alcohol use was assessed using the Alcohol Use Disorders Identification Test-Concise (AUDIT-C), 25 a brief 3-item alcohol screening tool. Past-year substance use was measured using Drug Abuse Screening Test (DAST-10), 26 a self-report measure with 10 binary items (0 or 1). Participant race and ethnicity was self-reported; this demographic information is collected routinely in our studies because treatment response and suicide risk has differed across racial and ethnic groups. We did not collect additional information about the specific racial groups in the other race category. Statistical Analysis Primary Outcome Data were analyzed from April 2024 to October 2025. For our primary outcome of composite suicide behavior, we used a Cox proportional hazards survival regression model 27 , 28 to calculate hazard ratios (HRs). All primary analyses were conducted under the ITT framework. Analyses were adjusted for enrollment site and lifetime suicide attempt history at baseline. Treatment condition was the primary variable. Time to event was defined as the number of days from randomization to the first suicide behavior. Because the first occurrence of suicide behavior per participant was included in the analysis, each event reflects a unique participant. Participants with no suicide behavior during the follow-up period were right censored at 365 days, and those with incomplete follow-up (and without data in their medical records) were right censored at their last available day. Kaplan-Meier estimates of the cumulative hazard function for both groups were plotted, and the proportional hazards assumption was verified with the Grambsch and Therneau 29 test for the global model. Analyses were conducted using R, version 4.4.2 (R Core Team), and 2-sided P values less than 0.05 were considered statistically significant. Post Hoc Analysis With Actual Suicide Attempts We also used the previously described analytic strategy with actual suicide attempt as the sole outcome. 16 This analysis was not prespecified and should be considered exploratory. Secondary and Exploratory Outcomes Secondary (ie, depression severity, hopelessness, attitudes toward seeking professional psychological help, outpatient mental health care use, and SRC) and exploratory (ie, thwarted belongingness) outcomes were analyzed using linear mixed effects (LME) regression models. All LMEs included fixed effects for randomization condition, time (treated as a factor, with baseline as the reference point), their interaction, and an adjustment for site (with the primary site as the reference). The treatment effect of PLF vs TAU was operationalized as the treatment-by-time interaction. Treating study time point (months 3, 6, and 12) as a factor allowed direct comparisons of treatment effects at each individual time point rather than assuming an overall linear trend. LMEs accommodate dropout or missing data under the assumption of missing at random, which was verified using Little’s 30 missing completely at random tests ( P > .05 for all time points). All models were fit with the ITT principle. After these outcome models, we examined the direct effect of treatment condition on belongingness using the mixed-effects models described above. Mediation analyses were conducted only if this effect was statistically significant. In secondary analyses, models with primary, secondary, and exploratory outcomes were conducted with a modified ITT sample consisting of those that attended at least 1 session of PLF with TAU. Results The sample included 207 participants (101 randomized to PLF and 106 to TAU), among whom 178 (86.0%) were male and 29 (14.0%) were female, and the mean (SD) age was 46.1 (13.9) years. One participant (0.5%) self-identified as American Indian or Alaska Native, 4 (1.9%) as Asian, 71 (34.3%) as Black or African American, 69 (33.3%) as Hispanic or Latino, 80 (38.6%) as White or Caucasian, 26 (12.6%) as multiracial, and 19 (9.2%) as other race. Participant characteristics and descriptives are presented in Table 1 . No study-related adverse events occurred. Table 1. Baseline Demographic and Clinical Characteristics (N = 207) a . Characteristic No. (%) Sex Men 178 (86.0) Women 29 (14.0) Race American Indian or Alaska Native 1 (0.5) Asian 4 (1.9) Black or African American 71 (34.3) White or Caucasian 80 (38.6) Multiracial 26 (12.6) Other b 19 (9.2) Ethnicity Hispanic or Latinx 69 (33.3) Non-Hispanic or non-Latinx 124 (59.9) Education level Some high school 1 (1.4) High school diploma or GED 54 (26.1) Some college or 2-y degree 104 (50.2) Bachelor’s degree 30 (14.5) Master’s degree 5 (2.4) Employment status Full-time 36 (17.4) Part-time 8 (3.9) Unemployed 79 (38.2) Student 12 (5.8) Retired 54 (26.1) Self-employed 5 (2.4) Marital status Married or cohabiting with someone as if married 46 (22.2) Widowed 4 (1.9) Divorced or annulled 57 (27.5) Separated 33 (15.9) Never married 57 (27.5) Baseline treatment status Not currently receiving psychiatric treatment 4 (1.9) Receiving outpatient mental health care 93 (44.9) Current psychiatric hospitalization 90 (43.5) Partial hospitalization program or other institutional living situation 9 (4.4) Family member or close friend supports treatment Yes 158 (76.3) No 37 (17.9) No. of offspring 0 66 (31.9) 1-2 74 (35.7) ≥3 86 (42.5) Lives alone Yes 108 (52.2) No 88 (42.5) Suicidal ideation or suicide attempt before military Yes 41 (19.8) No 154 (74.4) Served time in prison Yes 41 (19.8) No 147 (71.0) Psychiatric diagnosis at baseline c Current major depressive episode Yes 156 (75.4) No 26 (12.6) Past major depressive episode Yes 117 (56.5) No 65 (43.5) Posttraumatic stress disorder Yes 136 (65.7) No 61 (29.5) Generalized anxiety disorder Yes 124 (59.9) No 67 (32.4) Antisocial personality disorder Yes 42 (20.3) No 155 (74.9) Past substance abuse Yes 71 (34.3) No 116 (56.0) Past alcohol abuse Yes 62 (30.0) No 124 (59.9) Lifetime suicidal behavior or attempt history at baseline d Aborted suicidal behavior Yes 59 (28.5) No 136 (65.7) Interrupted suicidal behavior Yes 42 (20.3) No 154 (74.4) Actual suicide attempt e Yes 151 (73.0) No 55 (26.6) Open in a new tab Abbreviations: C-SSRS, Columbia-Suicide Severity Rating Scale; GED, general education degree. a Responses were optional, so category responses and percentages per category do not total 207 or 100%. b This category includes any race that was not designated above. The study did not collect additional information about the specific racial groups in this category. c Assessed with the Mini-International Neuropsychiatric Interview. 24 d Assessed with the C-SSRS. 16 e Because lifetime actual attempts were a covariate in the primary analysis, information for individuals missing the C-SSRS was obtained using chart reviews. PLF Session Attendance Among the 101 veterans randomized to PLF, 70 (69.3%) attended at least 1 session, of whom 46 (65.7%) completed at least 6 group sessions. The remaining 31 veterans (30.7%) did not attend any PLF sessions. Table 2 presents session attendance and treatment trial descriptive data. Table 2. Treatment Trial Descriptive Data. Variable PLF (n = 101) TAU (n = 106) Total (N = 207) First suicidal behavior, No. (%) a Any suicidal behavior 22 (21.8) 29 (27.4) 51 (24.6) Actual suicide attempt 15 (14.9) 28 (26.4) 43 (20.8) Aborted attempt 7 (6.9) 1 (0.9) 8 (3.9) Interrupted attempt 0 0 0 Deaths during the study period, No. (%) Suicide deaths 1 (1.0) 1 (0.9) 2 (1.0) Nonsuicide deaths 0 2 (1.9) 2 (1.0) PLF sessions attended, No. (%) 0 Sessions 31 (30.7) NA NA 1-5 Sessions 24 (23.8) NA NA 6-10 Sessions 36 (35.6) NA NA 11-12 Sessions 10 (9.9) NA NA Open in a new tab Abbreviations: PLF, Project Life Force; NA, not applicable; TAU, treatment as usual. a One participant was removed from the survival analyses with these data due to missing information regarding a lifetime suicide attempt, which was adjusted for in those models. Suicidal behaviors (primary outcome) were recorded as described in the Methods section, and all behaviors were submitted to the US Department of Veterans Affairs institutional review board. Primary Outcome During the study period, 51 individuals (24.6%) experienced a suicide behavior composite outcome, including interrupted, aborted, or actual suicide attempt or death by suicide (29 [27.4%] in TAU and 22 [21.8%] in PLF). Among these individuals, 43 (84%) experienced an actual attempt (28 [26.4%] in TAU and 15 [14.9%] in PLF) ( Table 2 ). There were 2 deaths by suicide, 1 in each arm. In the primary survival analysis, treatment condition was not significant for suicide behavior (HR, 0.73; 95% CI, 0.42-1.28; P = .27) ( Figure 2 ). Adjustments for site and lifetime suicide attempts were not significant. In the post hoc survival analysis, PLF participants had lower risk than TAU participants of time to first actual attempt (HR, 0.49; 95% CI, 0.26-0.92; P = .03) ( Figure 2 ). All model hazards were proportional. The addition of sex as a covariate did not change our findings. Figure 2. Survival Curves and Risk Tables for Suicidal Behavior and Actual Suicide Attempt Stratified by Treatment Condition. Open in a new tab Survival probability is plotted over time in days (0-365) to suicidal behavior and suicide attempt for participants randomized to treatment as usual (TAU) and Project Life Force (PLF) plus TAU. Vertical lines denote right-censored data. Secondary and Exploratory Outcomes Treatment-by-time effects for depression, hopelessness, and outpatient mental health use were nonsignificant ( Table 3 ). Attitudes toward seeking professional psychological help significantly improved at the 3-month follow-up (estimate, 2.14; Cohen d , 0.25; P = .01), and positive expectations toward the future significantly improved at 9-month follow-up (estimate, 1.17; Cohen d , 0.24; P = .02) in PLF relative to TAU ( Table 3 ). Overall SRC significantly improved in PLF relative to TAU at posttreatment (estimate, 4.06; Cohen d , 0.21; P = .04) and 3-month follow-up (estimate, 5.36; Cohen d , 0.27; P = .007) ( Table 3 ). External coping significantly improved at posttreatment (estimate, 2.09; Cohen d , 0.24; P = .02) and 3-month follow-up (estimate, 1.74; Cohen d , 0.19; P = .047), while internal coping significantly improved at 3-month follow-up only (estimate, 2.89; Cohen d , 0.35; P < .001) for the PLF arm vs the TAU arm. AUDIT-C and DAST-10 scores did not significantly differ at month 12. The INQ subscale of thwarted belongingness was nonsignificant; however, INQ perceived burdensomeness significantly improved at the 3-month follow-up from treatment in PLF relative to TAU (estimate, −3.52; Cohen d , −0.20; P = .04) (eTable 1 in Supplement 2 ). Because the direct effect of treatment condition on thwarted belongingness was not significant, exploratory mediation analyses were not pursued further. The addition of sex as a covariate did not change these findings. Table 3. Secondary Outcomes. Variable BDI-II (n = 207) BHS (n = 207) BHS-P (n = 207) SRCS (n = 207) SRCS-E (n = 207) SRCS-I (n = 207) ATSPPH (n = 205) Mental health visit (n = 194) Estimate (Cohen d ) P value Estimate (Cohen d ) P value Estimate (Cohen d ) P value Estimate (Cohen d ) P value Estimate (Cohen d ) P value Estimate (Cohen d ) P value Estimate (Cohen d ) P value Estimate (Cohen d ) P value No. of observations 584 NA 587 NA 587 NA 589 NA 589 NA 589 NA 564 NA 580 NA Intercept 31.02 <.001 a 9.21 <.001 a 5.51 <.001 a 48.93 <.001 a 20.12 <.001 a 21.05 <.001 a 21.79 <.001 a 20.89 <.001 a Treatment b 1.08 (0.06) .61 0.74 (0.09) .43 −0.65 (−0.16) .13 −0.89 (−0.06) .59 −0.55 (−0.08) .44 −0.21 (−0.03) .74 0.45 (0.06) .57 0.00 (0) >.99 Month 3 −7.24 (−0.48) <.001 a −1.80 (−0.26) .009 a 0.41 (0.12) .22 1.66 (0.12) .21 0.69 (0.11) .24 0.40 (0.07) .45 −0.39 (−0.07) .50 −0.68 (−0.04) .73 Month 6 −5.30 (−0.34) .001 a −1.64 (−0.23) .02 a 0.43 (0.12) .21 0.22 (0.02) .87 0.60 (0.10) .32 −0.35 (−0.06) .53 −1.34 (−0.23) .03 a 3.44 (0.18) .08 Month 12 −8.25 (−0.54) <.001 a −1.72 (−0.24) .01 a 0.26 (0.07) .45 3.36 (0.25) .01 a 1.56 (0.26) .01 a 1.01 (0.18) .06 0.08 (0.01) .89 NA NA Site (reference, JJPVAMC) CMJCVA −1.15 (−0.08) .58 0.33 (0.05) .72 −0.13 (−0.04) .75 1.66 (0.15) .30 0.89 (0.18) .19 0.59 (0.14) .31 1.07 (0.19) .17 −8.83 (−0.50) <.001 a CTVCS −1.71 (−0.07) .62 −0.31 (−0.03) .84 0.36 (0.07) .61 −0.71 (−0.04) .79 −0.15 (−0.02) .90 −0.40 (−0.06) .68 −1.67 (−0.17) .22 −6.97 (−0.25) .09 Treatment × month 3 −0.76 (−0.03) .73 −0.90 (−0.09) .37 0.76 (0.16) .11 4.06 (0.21) .04 a 2.09 (0.24) .02 a 1.08 (0.13) .17 1.37 (0.16) .11 1.92 (0.07) .50 Treatment × month 6 −2.80 (−0.12) .21 −0.65 (−0.06) .53 0.51 (0.10) .30 5.36 (0.27) .007 a 1.74 (0.19) .047 a 2.89 (0.35) <.001 a 2.14 (0.25) .01 a 3.43 (0.12) .23 Treatment × month 12 −0.73 (−0.03) .74 −1.36 (−0.13) .18 1.17 (0.24) .02 a 3.44 (0.17) .08 1.61 (0.18) .06 1.20 (0.15) .13 1.18 (0.14) .17 NA NA Open in a new tab Abbreviations: ATSPPH, Attitudes Toward Seeking Professional Psychological Help Scale–Short Form; BDI-II, Beck Depression Inventory-II; BHS, Beck Hopelessness Scale; BHS-P, BHS Positive Expectation Subscale; CMJCVA, Corporal Michael J. Crescenz Veterans Affairs Medical Center; CTVCS, Central Texas Veterans Health Care System; E, external; I, internal; JJPVAMC, James J. Peters Veterans Affairs Medical Center; NA, not applicable; SRCS, Suicide-Related Coping Scale. a Represents a statistically significant value ( P < .05). b Treatment is operationalized as PLF plus TAU (coded as 1) vs TAU (coded as 0). Secondary Analysis Modified ITT models for the primary outcome are detailed in eResults 1 and eTable 2 in Supplement 2 . Models with the secondary and exploratory outcomes are detailed in eResults 2 and eTable3 in Supplement 2 . Discussion This study evaluated whether PLF, a group SSP intervention, reduced time to suicide behavior using a composite of suicide behaviors, including suicide deaths, actual attempts, and aborted and interrupted attempts aggregated from 3 data sources within an ITT framework. Our primary outcome, time to first suicide behavior, did not differ by treatment arm. However, time to first actual suicide attempt was significantly longer for the PLF arm. Given the relative rarity of actual suicide attempts, the inclusion of aborted and interrupted attempts in a composite outcome served to increase statistical efficiency and trial feasibility. 31 However, after data collection, an unanticipated discrepancy emerged in the distribution of suicide behavior event types in the composite across the 2 study arms. In TAU, nearly all incidents (28 of 29) were classified as actual suicide attempts. In contrast, PLF included a mix of attempt types (22 total events; 15 actual attempts and 7 aborted). This divergence suggests that the composite outcome may have obscured clinically meaningful differences between groups. One possible interpretation is that PLF shifted the trajectory of suicide behavior away from more severe outcomes (ie, actual attempts) toward less severe or interrupted behavior. Indeed, individuals with actual attempts have been found to represent higher clinical severity compared with other behaviors. 32 People who ultimately abort a suicide attempt may follow a different decision-making process than those who do not abort their attempt. 33 Consistent with this interpretation, the finding for actual suicide attempt emerged from a secondary (post hoc) analysis and should be interpreted cautiously. Our finding suggests a potential mechanism whereby increased coping and safety plan use may interrupt progression to more severe suicide behavior. Thus, our findings reinforce the importance of differentiating among actual, aborted, and interrupted suicide behavior to advance suicide research and prevention considering the meaningful distinctions among these types of behavior. 34 Distinguishing between these behaviors is a strength of the C-SSRS and, thus, our study methodology. 35 , 36 Regarding our secondary outcomes, hopelessness and depression decreased across the trial in both treatment arms, consistent with past suicide prevention RCTs. 37 , 38 Other differences favoring PLF were more limited, including improved attitudes about seeking psychological care at month 6 and more positive expectations about the future at month 12. These results may suggest that PLF treatment strategies (ie, homework to share SSP with other clinicians) (eMethods in Supplement 2 ) strengthen veterans’ connections with their mental health team and foster hope, although these effects were not consistent across time points. PLF demonstrated significant improvements in overall SRC and self-reported use of external resources (eg, better use of outside supports, reaching out to clinicians, knowledge of emergency resources) at 3 and 6 months, and use of internal coping (items on self-efficacy, internal coping strategies) improved at month 6. These improvements likely followed session content that specifically targeted the teaching of skills relevant to augmenting use of the SSP, and a session centered on the Veterans Crisis Line with homework practice to contact 988 (eMethods in Supplement 2 ). Of note, thwarted belongingness was not significant. However, veterans in PLF demonstrated significant decreases in another INQ subscale, perceived burdensomeness. This pattern may reflect the group-based format of PLF and encouragement of open sharing and disclosure about suicidal symptoms each session. 39 Group therapy facilitates learning from others, supports the sharing of strategies for implementation of each SSP step, and enhances recognition that others are also experiencing suicidal concerns. Nonadherence was substantial ( Table 2 ). Although this nonadherence may have attenuated treatment effects, this dilution is an inherent feature of ITT analyses, which preserve the benefits of randomization and are considered a best practice for RCTs. 40 , 41 , 42 , 43 Attrition may be due to logistical constraints with group delivery, preferences for individual-focused treatment, or discomfort with suicide disclosure in a group setting. Future implementation-focused research could study ways to enhance engagement 44 with strategies such as peer support, given the presumed importance of group cohesion, 45 and technology enhancements. 46 , 47 TAU varied considerably between participants, including variability in individual treatment compliance, treatment, and therapist availability across sites, particularly during the pandemic. In addition, eligible veterans with suicide attempts during the previous year could participate in VA suicide prevention telehealth hubs that launched online near the end of the trial; these specialized psychotherapy treatments greatly enhanced TAU. Although TAU was guided by national VA standards, substantial heterogeneity occurred over time. This variability, particularly during and attributable to the COVID-19 pandemic, may have attenuated between-group differences. Efforts to better characterize and define TAU in future trials may help clarify the unique impacts of add-on treatments. Lastly, the global pandemic’s impact on the trial cannot be underestimated. 48 The Bronx site was the epicenter of COVID-19 infections for New York, with all in-person care prohibited except for emergencies and COVID-19 care. The Philadelphia VA site was closed to recruitment and not allowed to conduct research for more than 1 year. Several participants died from COVID-19 complications during the follow-up period. The pandemic also necessitated a transition from in-person to virtual PLF delivery and broadly affected mental health, stress, health care access, and study procedures. These factors were not formally modeled and likely influenced engagement and outcomes. 49 , 50 Limitations Limitations of the study include a higher-than-expected attrition, particularly between consent and randomization. Participants were often consented during psychiatric hospitalization and scheduled their baseline assessments after discharge; postdischarge is a time of enhanced suicide risk and instability. 51 Our noncompletion rate was higher than other multisession group interventions, 38 , 52 which may be due to pandemic-related factors that diluted the impact of the PLF intervention and also disrupted TAU services. A clearer definition of TAU is warranted in future clinical trials. 40 , 41 We recruited across 4 sites, but the geographic diversity of the sample remains limited, which may limit generalizability. We were unable to measure group cohesion in the virtual groups, which may be an important change mechanism of PLF and should be studied in future trials. Pandemic-related disruptions, including changes in delivery modality, were not formally modeled and may have influenced results. Conclusions In this RCT of 207 veterans, assignment to PLF did not reduce time to first instance of suicide behavior within an ITT framework but was associated with longer time to first actual suicide attempt. Although the finding for actual suicide attempt was not based on a prespecified primary outcome, it suggests that PLF may influence the severity or trajectory of suicide behavior. PLF was also associated with improvements in suicide-related coping and select secondary outcomes. While PLF was studied primarily in urban areas, its transition to virtual delivery during the pandemic allows extension to less populated and rural communities. Future PLF studies can target a wider geographic area and other veteran cohorts with elevated risk for suicide, including recently discharged service members and veterans not engaged in VA care. Supplement 1. Trial Protocol jamanetwopen-e2615029-s001.pdf (293.8KB, pdf) Supplement 2. eMethods. Project Life Force (PLF) Session Content eTable 1. Exploratory Outcomes eResults 1. Primary Outcome With a Modified Intent-to-Treat Sample eResults 2. Secondary and Exploratory Outcomes With a Modified Intent-to-Treat Sample eTable 2. Secondary Outcomes With a Modified Intent-to-Treat Sample eTable 3. Exploratory Outcomes With a Modified Intent-to-Treat Sample jamanetwopen-e2615029-s002.pdf (220.3KB, pdf) Supplement 3. Data Sharing Statement jamanetwopen-e2615029-s003.pdf (17.3KB, pdf) References 1. US Department of Veterans Affairs; Office of Mental Health and Suicide Prevention . 2025 National veteran suicide prevention annual report. 2026. Accessed March 15, 2026. https://www.mentalhealth.va.gov/docs/data-sheets/2025/2025_Annual_Report_Part_1_508.pdf 2. Stanley B, Brown GK, Karlin B, Kemp JE, VonBergen HA. Safety plan treatment manual to reduce suicide risk: veteran version. US Department of Veterans Affairs. 2008. Accessed September 5, 2025. www.suicidesafetyplan.com 3. Stanley B, Brown GK. 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