Clinical Practice Guideline Updated for Service Members and Veterans at Risk for Suicide

[Editor’s note: This article deals with mental health issues and treatment. If you or someone you know is having a mental health crisis, call the 988 National Suicide and Crisis Lifeline and press “1”, or text 838255, or chat for the dedicated Veterans Crisis Line and Military Crisis Line. For Spanish, press “2”.]
For adults who served or current active duty military at high risk of suicidal thoughts or actions, new guidance for clinicians can streamline the help they need.
Updated clinical practice guidelines, otherwise known as CPGs, from the Department of Defense and the Department of Veterans Affairs are an essential tool in assessing and managing patients and offer evidence-based recommendations for health care providers, according to Isabella Alvarez, nurse administrator coordinator, DOD program management for VA-DOD clinical practice guidelines.
A joint VA-DOD working group announced in May 2024 the release of the revised guideline, “The Assessment and Management of Patients at Risk for Suicide (2024),” to aid in critical decision points, Alvarez said. The VA-DOD Evidence-Based Practice Working Group was chartered by the VA-DOD Health Executive Committee in 1998.
The document updates the 2019 CPG based on a 2022 decision by the working group on the need to incorporate expanded evidence in this clinical area.
The guideline is intended for use across the VA and the Military Health System for service members, beneficiaries, and veterans who choose or need to be treated within their respective health care systems. The CPG is also available for community providers and others in the health care team involved with the assessment and management of adult patients at acute risk for suicide.
The updated CPG is based on information gathered by the working group and other mental health care experts from a variety of disciplines.
These experts systematically reviewed both current clinical evidence and epidemiological evidence, the latter on how often and why suicidal behaviors occur in particular populations. The CPG “provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation,” according to a provider summary.

Significant Revisions

The 2024 version contains a number of significant revisions that offer tangible strategies for practitioners by providing a roadmap and resources for how to apply them to service members, beneficiaries, and veterans, including:
• Updated algorithm of assessment and management
• Critical outcomes of suicide attempts and deaths by suicide included in the studies reviewed
• Eight new recommendations, with 12 reviewed and replaced from 2019, three amended, and one with no change
• More rigorous application of the Grading of Recommendations Assessment, Development and Evaluation method of measuring quality of evidence and strength of recommendations in health care
• Updated routine care for suicide prevention section
• Updated research priorities section
The algorithm represents a simplified clinical management flow of patients at heightened risk for suicide and helps foster efficient decision-making by providers. Model A helps identify those who are high risk; Model B helps providers assess the state of the patient’s mood and risk; and Model C aids providers in their management of adult patients at very serious risk of suicidal thoughts and actions.
“It’s very encouraging to note a significant increase in high-quality studies on suicide prevention and intervention since the last CPG was produced in 2019,” said Kate McGraw, who holds a doctorate in clinical psychology, and is chief of the Defense Health Agency’s Psychological Health Center of Excellence.
“These new studies allowed us to fine-tune recommendations based on more evidence than we had during the last CPG” in 2019, said McGraw, pointing to the grading methodology used. “These changes resulted in updated decision algorithms, and the development of eight new recommendations.”
The body of research on suicide risk-management, suicide prevention, interventions, and postvention in the aftermath of a death by suicide continues to grow. The new CPG includes updated recommendations on these key topics:
• Universal screening
• Screening tool selection
• Dialectal behavior therapy, a type of talk psychotherapy
• Infusion of the anesthetic drug ketamine to temporarily halt suicidal thinking
The CPG also provides advice on acute warning signs, predictive analytics, risk stratification, and risk management, including lethal means safety, and post-acute care, among other recommendations.

Patient Summary of Care

For DOD or VA patients, the CPG includes a summary of care and straightforward advice.
The advice includes getting help as the first step in a mental health crisis. “Your safety and improving your symptoms are the priorities. The goal is to decrease symptoms and lessen thoughts of hurting yourself, while planning for times when concerning thoughts happen,” according to the summary.
It notes there are “different interventions like talk therapy, medications, and decreasing access to lethal means that have been shown to help decrease the drivers and behaviors that could lead to harming oneself.” The summary briefly and simply explains the terms talk therapy, skill and strategies development in an individual or group setting, and the use of medication to reduce symptoms, as well as a combination of options.
The CPG also includes how and why patients need and get help, including reaching out through phone calls, email communications, and home visits. The best treatment may include patients and providers working together to develop a safety plan or crisis management response plan to help patients cope in the future, according to the CPG’s document for patients.
A pocket flow chart guide is also available for use by mental health intake personnel and treatment and management professionals.
McGraw called the 2024 CPG a “valuable resource for everyone on the team: providers, patients, family members, non-provider professionals, line leaders, and for civilian communities that support our military and veterans.”
The CPG’s clinical support tools “serve as more concise resources to support all members of the team who may be called upon to prevent a service member or veteran death by suicide,” she noted.

Resources

For anyone experiencing a mental health crisis, needing immediate assistance, or simply wanting to talk, confidential help is available 24/7/365.
Military OneSource is a 24/7 gateway to trusted information for service members and families that provides resources and confidential help. Call 800-342-9667.

The Psychological Health Resource Center is available 24/7 for service members, veterans, and family members with questions about psychological health topics. Trained mental health consultants can help you access mental health care and community support resources in your local area. Call 1-866-966-1020, start a live chat, or visit www.health.mil/PHRC.

The inTransition program has 20 FAQs that are a helpful introduction to the program. You can call 800-424-7877, or at 800-748-81111 in Australia, Germany, Italy, Japan, and South Korea only. You can also email the program directly at:dha.ncr.j-9.mbx.inTransition@health.mil.

The MHS, Department of Defense, and the Department of Veterans Affairs have many other mental health resources available to any service member, family, or veteran beneficiaries who are struggling with mental health challenges. Go to our Mental Health Hub for a complete list of resources for immediate assistance or to make appointments.

To set up a mental health appointment through TRICARE, visit: www.tricare.mil/MentalHealth.

Check out our toolkit to participate in DHA’s Mental Health Awareness Month Campaign.
Public Outreach
Other critical areas of public outreach are available across the armed services. These include:
• Educating and training service members to see signs and reduce suicide risks through the:
o U.S. Army’s Suicide Prevention efforts
o U.S. Air and Space Force’s Ask, Care, Escort program
o U.S. Navy’s Ask, Care, Treat program
• Increasing service members’ knowledge and comfort for reaching out to help resources via the Defense Suicide Prevention Office’s Resources Exist, Asking Can Help program, or REACH
• Encouraging supportive language through DSPO’s Your Words Matter campaign, which calls for the end of stigmatizing or negative language when addressing mental health
• Sharing resources to support service members and their families through the Healthy Relationship program, a free, educational consultation designed to strengthen relationships through a series of personalized coaching sessions tailored to help set goals and strengthen communication skills
• Collaborating with the DOD Educational Agency to support school-age children in talking about their feelings via the Acknowledge, Care, Tell program