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Principal Investigator: Lauren M Denneson
Organization: PORTLAND VA MEDICAL CENTER
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: The suicide rate among female Veterans increased 63% between 2000 and 2014 – significantly
higher than the 30% increase observed among male Veterans during this period. Despite a large volume of
work examining risk factors, barriers to care, and care utilization among Veterans, little research has examined
these issues as they relate to females. Available research has been limited by small female sample sizes,
cross-sectional analysis, and other methodological limitations. As such, we know surprisingly little about the
health and psychosocial factors, barriers to care, and healthcare utilization patterns associated with suicidal
behaviors among female Veterans. Data on female risk for suicide and their healthcare utilization is needed to
direct valuable suicide prevention resources and help VHA address this growing and serious problem.
Objectives: The goal of our research is to inform gender-tailored suicide prevention approaches, using a large,
national sample of female and male Veterans with recent non-fatal suicidal self-directed violence (SSV: fatal
and non-fatal suicide attempts). We aim to: 1) Develop and test explanatory models of female and male risk for
repeat SSV over 12 months, and 2) Identify similarities and differences in patterns of healthcare utilization,
coping strategies, and symptom change over time between female and male Veterans at risk for SSV.
Methods: This will be the first mixed-methods, longitudinal cohort study of Veterans with a history of SSV, and
is guided by a public health, social-ecological framework to facilitate examination of the range of proximal and
distal risks for SSV. First, we will identify and enroll 30 female and 30 male Veterans for whom a non-fatal SSV
event was recorded in a suicide behavior report in VA's Corporate Data Warehouse (CDW). These 60
Veterans will participate in qualitative interviews to gather data on Veterans' perspectives and experiences with
suicidal thoughts and SSV, their recovery needs and experiences with the recovery process, barriers and
facilitators to care, and how clinicians and the healthcare system could better identify and address the needs of
Veterans like them. We will use a grounded theory approach to analyze transcripts to develop a theoretical
model of risk for SSV among female Veterans, directly informing survey construct selection, quantitative
analysis plans, and interpretation of quantitative findings. For the longitudinal survey, we will use suicide
behavior reports in CDW to identify and enroll at least 480 female and 480 male Veterans, who will complete
health and psychosocial measures at baseline, 6- and 12-month follow up. Self-report questionnaires will be
informed by the qualitative findings and include psychosocial and health-related measures such as coping
efficacy, interpersonal conflict, positive relations with others, trauma, occupational problems, barriers to care,
and mental health symptoms. Participants will be followed for 12 months to assess and document all SSV
events (primary outcome: an SSV event following baseline), which will be ascertained via multiple sources.
Health and utilization data will be obtained from CDW and medical record progress notes. Main quantitative
analyses will use a latent variable modeling framework to simultaneously model males and females in a multi-
group format to test models of female and male Veteran suicide risk. We will then use latent class and latent
transition analysis to identify differential responses to healthcare utilization and how certain health and
psychosocial variables cluster together by gender.
Significance: Findings from this study will provide previously unavailable evidence to support the selection of
intervention targets as well as identify high-priority services and barriers to care to direct programing and
research priorities for female Veterans at risk for SSV. This work has the potential to also benefit the broader
population of female Veterans with mental health conditions or other risk factors for SSV.
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