Veteran suicide prevention learning collaborative: implementation strategy and processes.

The majority of Veterans who died by suicide in 2021 had not recently used Veterans Health Administration (VA) services. A public health approach to Veteran suicide prevention has been prioritized as part of the VA National Strategy for Preventing Veteran Suicide. Aligned with this approach, VA's Patient Safety Center of Inquiry-Suicide Prevention Collaborative piloted a Veteran suicide prevention learning collaborative with both clinical and non-clinical community agencies that serve Veterans. The VA COmmunity LeArning CollaboraTive (CO-ACT) uses a quality improvement framework and facilitative process to support community organizational implementation of evidence-based and best practice suicide prevention strategies to achieve this goal. This paper details the structure of CO-ACT and processes by which it is implemented. This includes the CO-ACT toolkit, an organizational self-assessment, a summary of recommendations, creation of a blueprint for change, selection of suicide prevention program components, and an action plan to guide organizations in implementing suicide prevention practices. CO-ACT pilot outcomes are reported in a previous publication.

Improving primary care access for rural women Veterans: the Boost Team.

Objectives: To improve healthcare access for rural cisgender women and gender diverse Veterans, we created the "Boost Team," a clinician-driven telehealth outreach service to connect this population to Veterans Health Administration (VHA) services. Methods: Between 9/2021 and 2/2022, we conducted a needs assessment in the Veterans Integrated Service Network (VISN) 21 and used those data to develop an outreach intervention. We piloted a clinician-led outreach intervention in 3/2022, and formally deployed an outreach team in 9/2022. Results: The needs assessment uncovered opportunities to educate Veterans, staff, and clinicians about available VHA women's health services, and a need for easily-accessible gender-sensitive services. During the pilot, 58% (7/12) rural cisgender women Veterans were successfully contacted, all reported positive experiences with the intervention. The formal outreach team launched in 9/2022 and consists of a nurse practitioner (NP), scheduler, Peer Support Specialist, and medical director. From 9/2022 to 12/2022 the Boost NP called 110 rural cisgender women and gender diverse Veterans and spoke to 65 (59%) of them. Common care needs identified and addressed included care coordination, new referrals, medication management, and diagnostics. Discussion: Data from Boost show that clinician-led outreach can engage rural cisgender women and gender diverse Veterans in VHA services, there is a desire for more gender-sensitive services, and there is a need for systems-level improvements to allow for improved care coordination and decreased leakage outside of VHA. Using robust strategies grounded in implementation sciences, we will continue conducting a program evaluation to study the impact of Boost and scale and expand the program.

Impact of an internet-based insomnia intervention on suicidal ideation and associated correlates in veterans at elevated suicide risk.

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk.

In this secondary data analysis, we examined improvements in insomnia severity, suicidal ideation (SI), and suicide risk correlates in veterans with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) examining an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I). Veterans in the iCBT-I group experienced greater improvements in insomnia severity and hopelessness than veterans in the Insomnia Education Website control. Although between-group differences in SI and other suicide risk correlates were not statistically significant, effect sizes suggest that SI and symptoms of depression, irritability, concentration, post-traumatic stress disorder, and hostility may improve following iCBT-I intervention. These results suggest that digital and iCBT-I interventions may be especially powerful tools for use in suicide prevention among veterans but highlight the critical need for additional large-scale studies to examine suicide-specific mechanisms and outcomes to guide implementation efforts.

Suicide Prevention Programming: Comparing Four Prominent Frameworks.

OBJECTIVE: Suicide is a significant public health concern. About 48,000 individuals died by suicide in 2021 in the United States, and approximately one in 100 deaths globally are due to suicide. Continuing efforts in program development and evaluation are vital to preventing suicide. Multiple frameworks have been developed to reduce suicide rates, but they have not been compared to assess their comprehensiveness, nor have their components been classified. METHODS: In 2019, the authors conducted a narrative review of the literature and identified four major frameworks for suicide prevention: the U.S. Department of Veterans Affairs (VA) Suicide Prevention Program, the Defense Suicide Prevention Program of the U.S. Department of Defense, Zero Suicide in Health and Behavioral Health Care, and the technical package developed by the Centers for Disease Control and Prevention. Program components for these frameworks were identified and classified by using two prevention strategy classification systems: the National Academy of Medicine's (NAM's) continuum-of-care model and the Substance Abuse and Mental Health Services Administration's (SAMHSA's) prevention model. RESULTS: The cross-program comparison revealed that no single program included all components of suicide prevention programs. However, the VA program was the most comprehensive in terms of the number of components and their spread across prevention strategy classifications. The programs used few components categorized under NAM's promotion or selective prevention strategy classifications. The SAMHSA prevention strategy classifications of information dissemination, community-based processes, and positive alternatives were also used infrequently. CONCLUSIONS: Organizations, health care systems, and policy makers may use these findings as they develop, improve, and implement suicide prevention programs.

"Something Has to Be Done to Make Women Feel Safe": Women Veterans' Recommendations for Strengthening the Veterans Crisis Line for Women Veterans.

OBJECTIVE: Women represent 15% of veteran callers to the Veterans Crisis Line (VCL); there has been little research identifying the experiences and needs of women veterans who use the VCL. The objective of this study was to identify women veterans' experiences with and recommendations for strengthening VCL services for women. METHOD: We conducted qualitative interviews with 26 women veterans across the United States who had contacted the VCL in the preceding year. Interviews were conducted by telephone in 2022 and were audio recorded and transcribed. A team-based content analysis approach was used to identify participants' concerns around contacting the VCL and recommendations for strengthening the service. RESULTS: Interviews revealed women veterans' concerns with regard to contacting the VCL related to responder gender, appropriateness of VCL services for veterans not at imminent risk for suicide, and potential consequences of contacting the VCL. Key recommendations included letting veterans select the gender of the responder who takes their call, providing more information to potential callers about what to expect from VCL calls, and raising awareness about and maintaining options for caller anonymity. CONCLUSIONS: This study uniquely focused on women veterans' experiences and perspectives, in their own voices. Findings point to trauma-informed approaches supporting women veteran callers to the VCL and may also hold implications for other similar crisis hotline services.

Suicide Among Asian American, Native Hawaiian, and Pacific Islander Veterans: Rates and Methods, 2005-2019.

INTRODUCTION: Knowledge of suicide rates and methods among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) Veterans remains sparse. Age- and sex-specific suicide rates, methods, and trends were examined among AANHPI Veterans and were compared with findings reported for all Veterans. METHODS: For this population-based retrospective cohort study, average annual suicide rates (2005-2019) were computed in 2023 using population (U.S. Veterans Eligibility Trends and Statistics) and mortality (National Death Index [NDI]) data. The cohort included 416,454 AANHPI Veterans (356,146 males, 60,229 females) separated from military service and alive as of 1/1/2005. Suicide was determined from NDI underlying cause-of-death ICD-10 codes. RESULTS: The age-adjusted average annual suicide rate among AANHPI Veterans increased 36.85% from 2005-2009 to 2015-2019 (2015-2019: 30.97/100,000). Relative to other ages, 2015-2019 suicide rates were highest among AANHPI Veterans 18-34 (overall: 53.52/100,000; males: 58.82/100,000; females: 32.24/100,000) and exceeded those of similarly aged Veterans in the overall Veteran population (overall: 44.71/100,000; males: 50.59/100,000; females: 19.24/100,000). The sex difference in suicide rates was lower among AANHPI Veterans than in Veterans overall (relative risk [males to females]=1.65 and 2.33, among those 18-54). Firearms were used less and suffocation more among AANHPI Veterans, relative to Veterans overall. CONCLUSIONS: Suicide among AANHPI Veterans is an increasing public health concern, with younger males and females at particularly elevated risk. Lethal means safety strategies for AANHPI Veterans should consider distinctions in suicide methods compared to the overall Veteran population. Research is warranted to understand the lower magnitude sex difference in suicide rates among AANHPI Veterans.

Women Veterans' perspectives, experiences, and preferences for firearm lethal means counseling discussions.

AIMS: Firearms have become an increasingly common method of suicide among women Veterans, yet this population has rarely been a focus in firearm suicide prevention research. Limited knowledge is available regarding the preferences, experiences, or needs of women Veterans with respect to firearm lethal means counseling (LMC), an evidence-based suicide prevention strategy. Understanding is necessary to optimize delivery for this population. METHOD: Our sample included forty women Veterans with lifetime suicidal ideation or suicide attempt(s) and firearm access following military separation, all enrolled in the Veterans Health Administration. Participants were interviewed regarding their perspectives, experiences, and preferences for firearm LMC. Data were analyzed using a mixed inductive-deductive thematic analysis. RESULTS: Women Veterans' firearm and firearm LMC perspectives were shaped by their military service histories and identity, military sexual trauma, spouses/partners, children, rurality, and experiences with suicidal ideation and attempts. Half reported they had not engaged in firearm LMC previously. For those who had, positive aspects included a trusting, caring relationship, direct communication of rationale for questions, and discussion of exceptions to confidentiality. Negative aspects included conversations that felt impersonal, not sufficiently comprehensive, and Veterans' fears regarding implications of disclosure, which impeded conversations. Women Veterans' preferences for future firearm LMC encompassed providers communicating why such conversations are important, how they should be framed (e.g., around safety and genuine concern), what they should entail (e.g., discussing concerns regarding disclosure), whom should initiate (e.g., trusted caring provider) and where they should occur (e.g., safe spaces, women-specific groups comprised of peers). DISCUSSION: This study is the first to examine women Veterans' experiences with, and preferences for, firearm LMC. Detailed inquiry of the nuances of how, where, why, and by whom firearms are stored and used may help to facilitate firearm LMC with women Veterans.

Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial.

BACKGROUND: Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans. OBJECTIVE: The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans. METHODS: We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters. RESULTS: Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported. CONCLUSIONS: Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach. TRIAL REGISTRATION: ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.

Identifying U.S. regions with the highest suicide rates and examining differences in suicide methods among Asian American, Native Hawaiian, and Pacific Islander Veterans.

The suicide rate among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) Veterans increased from 2001 to 2020. Identifying regions where suicide rates are elevated and increasing among AANHPI Veterans would inform targeted prevention efforts for members of this cohort. We conducted a population-based retrospective cohort study of 377,833 AANHPI Veterans to examine suicide rates and methods (2005-2019) by United States (US) region and over time (2005-2009, 2010-2014, 2015-2019), using US Veteran Eligibility Trends and Statistics and Joint DoD/VA Mortality Data Repository data. AANHPI Veterans across most regions experienced increases in suicide rates from the earliest to latest period; however, patterns differed by region. Age-adjusted suicide rates increased across all three periods among those in the Northeast and West, but increased, then declined in the Midwest and South. In 2015-2019, the age-adjusted suicide rate among AANHPI Veterans was highest in the Northeast (42.0 per 100,000) and lowest in the West (27.5). However, the highest percentages of AANHPI Veteran suicide deaths in 2005-2019 occurred in the West (39.5%) and South (34.7%), with lower percentages in the Midwest (15.0%) and Northeast (10.8%). Across regions, those ages 18-34 had the highest suicide rates. Firearms were the most frequently used suicide method across regions (44.4%-60.2%), except the Northeast (35.2%), where suffocation was more common (38.3%). Results suggest particular needs for suicide prevention efforts among AANHPI Veterans in the Northeast and to ensure that lethal means safety initiatives for AANHPI Veterans encompass both firearms and suffocation, with some variations in emphasis across regions.

Perspectives of VA healthcare from rural women veterans not enrolled in or using VA healthcare.

PURPOSE: Women Veterans have unique healthcare needs and often experience comorbid health conditions. Despite this, many women Veterans are not enrolled in the Veterans Health Administration (VHA) and do not use VHA services. Underutilization of VHA services may be particularly prevalent among rural women Veterans, who may experience unique barriers to using VHA care. Nonetheless, knowledge of rural women Veterans and their experiences remains limited. We sought to understand rural women Veterans' perceptions and needs related to VHA healthcare, including barriers to enrolling in and using VHA services, and perspectives on how to communicate with rural women Veterans about VHA services. METHODS: Rural women Veterans were recruited through community engagement with established partners and a mass mailing to rural women Veterans not enrolled in or using VHA healthcare. Ten virtual focus groups were conducted with a total of twenty-nine rural women Veterans (27 not enrolled in VHA care and 2 who had not used VHA care in the past 5 years) in 2021. A thematic inductive analytic approach was used to analyze focus group transcripts. FINDINGS: Primary themes regarding rural women Veterans' perceptions of barriers to enrollment and use of VHA healthcare included: (1) poor communication about eligibility and the process of enrollment; (2) belief that VHA does not offer sufficient women's healthcare services; and (3) inconvenience of accessing VHA facilities. CONCLUSION: Although VHA has substantially expanded healthcare services for women Veterans, awareness of such services and the nuances of eligibility and enrollment remains an impediment to enrolling in and using VHA healthcare among rural women Veterans. Recommended strategies include targeted communication with rural women Veterans not enrolled in VHA care to increase their awareness of the enrollment process, eligibility, and expansion of women's healthcare services. Creative strategies to address access and transportation barriers in rural locations are also needed.

Veteran Engagement in Survey Research to Prevent Suicide.

Suicide rates among veterans remain high, underscoring the necessity of identifying modifiable suicide risk and protective factors that can be targeted through public health approaches. One way to ensure that survey-based research yields information necessary to translate findings into patient-centered interventions is through veteran engagement. The current manuscript describes perspectives of members of a national Veterans Engagement Board (VEB) in contributing to the Assessing Social and Community Environments with National Data (ASCEND) for Veteran Suicide Prevention project. Contributions have included strengthening communication with potential veteran participants, addressing sensitive survey topics such as firearms and suicide, and ensuring that ASCEND is responsive to current national and global events. Additionally, Veterans Engagement Board members described the personal impact of engagement. These contributions highlight the value of veteran engagement as an integral component of suicide risk and prevention research.

Women Veterans' experiences discussing household firearms with their intimate partners: collaborative, devalued, and deferential relational types.

BACKGROUND: Rates of firearm suicide have increased among women Veterans. Discussing firearm access and reducing access to lethal means of suicide when suicide risk is heightened are central tenets of suicide prevention, as is tailoring suicide prevention strategies to specific populations. While research has begun to explore how to optimize firearm lethal means safety counseling with women Veterans, there is limited knowledge of women Veterans' perspectives on including their intimate partners in such efforts. This gap is notable since many women Veterans have access to firearms owned by other household members. Understanding women Veterans' experiences and perspectives regarding including their partners in firearm lethal means safety conversations can provide important information for tailoring firearm lethal means safety counseling for women Veterans. METHODS: Qualitative interviews were conducted with 40 women Veterans with current or prior household firearm access. Interview questions focused on the roles of women Veterans' partners in household firearm access and storage, as well as women Veterans' perspectives regarding including intimate partners in firearm lethal means safety counseling. Inductive thematic analysis was performed. RESULTS: Three relational types characterized how household firearms were discussed between women Veterans and their partners: collaborative, devalued, and deferential. These types were distinguished via women Veterans' agency in decision-making related to household firearms, partners' receptivity to women Veterans' mental health or trauma histories, and willingness (or lack thereof) of partners to change household firearm access and storage considering such histories. Intimate partner violence was common in the devalued relational subtype. CONCLUSIONS: Findings extend knowledge regarding the context of women Veterans' household firearm access, including relational dynamics between women Veterans and their partners. The acceptability, feasibility, challenges, and facilitators of including women Veterans' partners in firearm lethal means safety efforts likely vary for each relational type. For example, in dyads with a collaborative dynamic, incorporating partners may create opportunities for increased firearm safety, whereas including partners in devalued dynamics may present unique challenges. Research is warranted to determine optimal methods of navigating firearm lethal means safety counseling in the presence of each relational dynamic.

The perceived impact of pandemic scale (PIPS): Initial development and examination among U.S. military veterans.

The COVID-19 pandemic has had significant impacts, including increases in mental health problems, distress, interpersonal conflict, unemployment, loss of income, housing instability, and food insecurity. Veterans may be particularly vulnerable to such impacts given their burden of mental and physical health problems. Few existing measures assess pandemic impact, and none have been validated for use with Veterans. We developed such a measure (the Perceived Impact of the Pandemic Scale; PIPS) and examined its psychometric performance in a national sample of US Veterans. Survey data from 567 Veterans were collected between 12/2020 and 2/2021. To examine PIPS factor structure, split sample exploratory/confirmatory factor analyses (EFA/CFA) were conducted to identify and test the most plausible model among an initial set of 18 items. Based on tests of factor extraction and factor loadings, 15 items clearly loaded onto three distinct factors. Internal reliability of all factors was ω > 0.8 and CFA model fit was good (χ2(87) = 167.39, p < .001; SRMR = 0.068; RMSEA = 0.060 [95% CI: 0.05, 0.07], CFI = 0.92). Mean factor scores were significantly positively correlated with measures of depression and loneliness, and negatively correlated with perceived social support. Results suggest the PIPS assesses three internally reliable factors comprised of perceived impact of the pandemic on interpersonal relationships, financial impact, and personal health and well-being. Construct validity with US Veterans was supported. The PIPS may be useful for examining the potentially disparate impact of pandemics on different populations. Research is needed to validate the PIPS in non-Veteran populations.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes.

INTRODUCTION: Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. METHOD: The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. RESULTS: The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. CONCLUSION: Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

Military sexual trauma among Veterans using and not using VA justice-related programing: A national examination.

Veterans accessing Department of Veterans Affairs (VA) Veterans Justice Program (VJP) services have high rates of depression, substance misuse, and posttraumatic stress disorder. Although factors that may confer risk for mental health sequelae among these Veterans have been identified (e.g., childhood abuse, combat exposure), limited research has examined report of military sexual trauma (MST) among Veterans accessing VJP services. As survivors of MST experience myriad chronic health conditions which necessitate identification and referral to evidence-based care, identifying MST survivors among those accessing VJP services may facilitate referral to appropriate services. We examined whether MST prevalence differed between Veterans with and without a history of VJP service use. Sex-stratified analyses were conducted with 1,300,252 male (13.34% accessing VJP) and 106,680 female (10.14% accessing VJP) Veterans. In crude models, male and female Veterans accessing VJP services were significantly more likely to screen positive for MST (PR = 3.35 and 1.82 respectively). Significance was maintained in models that adjusted for age, race/ethnicity, VA service use, and VA mental health use. VJP service settings may serve as a critical intercept for identifying male and female survivors of MST. Using a trauma-informed approach to screen for MST in VJP settings is likely warranted. Moreover, integration of MST programing into VJP settings may be beneficial.

Suicide risk among veterans using VHA justice-involved services: a latent class analysis.

BACKGROUND: Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited. METHODS: We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018. RESULTS: A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide. CONCLUSIONS: Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.