Veteran Suicide Risk Evaluations: Key Insights From the VHA’s Comprehensive Evaluations

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A recent study found that suicidal ideation and firearm access are the strongest predictors of veteran suicide risk, providing critical insight regarding suicide risk indicators among US veterans receiving care through the Veterans Health Administration (VHA). The study, which analyzed over 269,000 suicide risk evaluations conducted from November 2019 to December 2020, identifies key factors that predict suicide risk within both 30 days and 1 year of assessment. Of the 153,736 veterans assessed, 791 died by suicide within 1 year, with 144 occurring within 30 days.¹

The study found that suicidal ideation was the most significant predictor of suicide within 30 and 365 days of evaluation, with a hazard ratio (HR) of 3.14 within 30 days and an HR of 1.63 within 1 year. Firearm access was another crucial factor, increasing the likelihood of suicide by 2.6 times within 30 days and by 1.5 times within a year. Firearms accounted for 72% of veteran suicides, compared with 52% among civilians.¹ In a written piece responding to the study, Rebecca C. Rossom, MD, clarified that nearly 90% of suicide attempts using firearms are fatal, compared with 5% using other means.

Additional behaviors linked to increased suicide risk included making preparations for a suicide attempt (HR 2.15 in 30 days, HR 1.56 withing 1 year), seeking access to lethal means (HR 2.04 within 30 days), and a history of psychiatric hospitalization (HR 1.63 within 30 days, HR 1.68 within a year). Veterans exhibiting reckless behaviors were also found to have an elevated risk within a year of assessment, with an HR of 1.40 within a year. Anxiety was associated with an 80% increase (HR 1.80) in suicide risk within 30 days of evaluation. Veterans identified as being intermediate acute risk had a 39% higher likelihood of suicide within a year (HR 1.39), while those deemed at high chronic risk had a 745 increased likelihood (HR 1.74).

The study found that some traditionally assumed protective factors, such as hope, social support, and access to mental health care, were not significantly associated with reduced suicide risk, suggesting that clinicians should focus more on mitigating high-risk behaviors rather than relying on protective factors alone. Anger was unexpectedly linked to a decreased risk of suicide within both 30 and 365 days, contradicting prior research that associates anger with higher suicide risk. Investigators say anger is commonly associated with posttraumatic stress disorder, which was associated with decreased chronic suicide risk.¹

“The findings that anger, preexisting risk factors, and recent transition from the military decreased risk are surprising, as they contradict findings in previous research and deserve further study,” Rossom wrote.²

The study findings indicate refining VHA’s Comprehensive Suicide Risk Evaluation (CSRE) to focus on the most predictive risk factors could improve suicide prevention efforts. Investigators also recommend integrating CSRE data into advanced risk prediction models to enhance clinical decision-making.¹ Reducing the number of assessment criteria that do not directly correlate with suicide risk may help streamline evaluations and improve accuracy.

Rossom wrote that the VHA’s efforts regarding suicide prevention are laudable and acknowledges efforts to normalize clinical conversations about suicide by mandating universal screening, considering 39% of veterans in VHA care who die by suicide have no documented mental health or substance use disorder diagnoses.² Given the strong correlation between firearm access and suicide, strategies such as secure firearm storage, temporary removal during crises, and increased counseling on firearm safety could be used to mitigate risk. Investigators say that the VHA invested in interventions to limit firearm access, such as gun locks, but veterans who died by suicide via firearms are less likely to have received lethal means safety counseling and had lower levels of suicide risk factors.¹

As suicide prevention remains a national priority, the study offers key data points for refining veteran suicide risk assessments, potentially leading to more targeted and effective interventions. The critical role of precise and timely risk evaluations in preventing suicide among veterans could mean that a more data-driven approach could save lives.

References

1. Saulnier KG, Bagge CL, Ganoczy D, et al. Suicide risk evaluations and suicide in the Veterans Health Administration. JAMA Netw Open. 2025;8(2):e2461559.

2. Rossom RC. Suicide risk detection and prevention—how the VHA can advance the evidence. JAMA Netw Open. 2025;8(2):e2461564.