Rates of death by suicide among Veterans remain high, with age- and sex-adjusted rates 1.5 times higher for Veterans than non-Veteran adults.1 This risk is especially pronounced among Veterans experiencing homelessness, who have particularly high rates of suicidal ideation and suicidal self-directed violence.2 This likely relates to the presence of multiple risk factors, including extreme poverty and lack of housing; loneliness and limited social support; a high prevalence of physical, psychiatric, and cognitive comorbidities; psychosocial stressors (eg, unemployment); and high rates of trauma exposure and interpersonal violence.3–7 While the intersection of these factors is likely impacted by a number of influences (eg, race, ethnicity, sex, rurality), in general, research to determine suicide risk and protective factors in this complex population remains limited and in need of further inquiry.
Recognizing the intersection of homelessness and suicide risk, the Department of Veterans Affairs (VA) is implementing strategies to integrate suicide prevention efforts into its service operations for Veterans experiencing homelessness. For example, the VA has implemented universal screening for suicidal ideation and recent suicide attempts among all Veterans using the Veterans Health Administration (VHA) care, including those experiencing homelessness.8 In the presence of elevated acute suicide risk (eg, recent suicidal ideation with intent), a comprehensive suicide risk evaluation is conducted, followed by the provision of appropriate care (eg, Safety Plan, hospitalization, evidence-based psychotherapy). Notably, this initiative has been implemented in settings that provide services to Veterans who have previously or are currently experiencing homelessness, such as in the US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH), Health Care for Homeless Veterans, Grant, and Per Diem.
The VA also provides Suicide Prevention Gatekeeper Training to help providers recognize when a Veteran is at increased risk for suicide and make appropriate referrals or connections to care. In addition, the VA has undertaken several tailored approaches specific to the needs of Veterans experiencing homelessness. For instance, given the wide range of non-VHA, community-based services that Veterans experiencing homelessness may access (eg, homeless shelters, community-based clinics), the VHA Homeless Programs Office has expanded Suicide Prevention Gatekeeper Training to a number of non-VHA organizations in the local community.6
While these initiatives are integral initial steps, additional understanding remains necessary to ensure that programming is appropriately tailored to Veterans experiencing homelessness. For example, additional information is needed regarding rates of screening, risk factors, and interventions to address suicide risk among Veterans experiencing homelessness who access either VHA or non-VHA care. In addition, evaluating suicide prevention training across VHA and non-VHA settings could reveal organizational wisdom and advice about the implementation of training in these dynamic environments. It is also important to remember that the roots of both suicide risk and homelessness for Veterans experiencing homelessness often extend back decades. As such, balancing preventive care, while also addressing acute housing instability and suicide risk, is likely necessary and in need of further evaluation.
Historically, most Veteran suicide-prevention initiatives (eg, screening for suicide risk) have focused on Veterans accessing VHA care. Yet Veterans experiencing homelessness may access a wide array of non-VA community services (eg, homeless shelters, community-based emergency departments),6 and many do not qualify for comprehensive VA services. Thus, the focus on homeless Veterans accessing VHA care limits the potential reach of these suicide prevention initiatives.9 Understanding the extent to which Veterans experiencing homelessness who are not utilizing VHA care to receive suicide risk assessment and documentation in the community requires VA and community-based collaboration and communication of risk and treatment planning. Furthermore, there remain unanswered questions around infrastructural needs to facilitate data sharing and harmonization between organizations, which could facilitate understanding the constellations of services aimed at detecting or preventing suicide risk among Veterans.
There is also limited research on which factors drive risk for suicide among Veterans experiencing homelessness and how these factors differ from those impacting suicide risk within the broader Veteran population. Longitudinal studies are needed to identify modifiable upstream and downstream risk factors that could inform the development or enhancement of evidence-based practices to reduce such risk among Veterans experiencing homelessness. However, given the time-intensive nature of longitudinal research, methodological designs, such as hybrid models, which assess therapeutic benefit while also implementing interventions to at-risk populations may be warranted.10 Mirroring clinical care, such efforts are likely to be multifaceted and—given the diversity of sites where Veterans experiencing homelessness may access care—will require new levels of collaboration and support among providers working in VA and in the community.6
As with the general population of Veterans, factors that influence suicide risk among Veterans experiencing homelessness include the intersectionality of sociodemographic factors (eg, race, ethnicity, sex), social determinants of health, personal perceptions of the VA, and the services it provides, and differences between rural and urban-dwelling Veterans. Moreover, working with populations that have a greater propensity for multiple comorbidities, extensive trauma histories, differing experiences of housing instability (eg, dwelling on the street vs. in transitional housing), and transient or unsafe living conditions can challenge our research infrastructure (eg, scientists, institutional review boards, funding agencies). Such challenges necessitate creativity and innovation around recruitment, data collection, and study designs; for example, utilizing mobile technology or linkages of administrative data systems (eg, VHA and community-based) to facilitate detection and intervention of suicide risk among Veterans experiencing homelessness. In addition, interventions with this population are often bundled and multifaceted (eg, collaboration with outpatient mental health providers or those working within the criminal justice system), requiring collaboration across researchers and agencies, as well as complex research designs, to ascertain best practices.
Because of this, the VA, through its Office of Research and Development and its National Center on Homelessness among Veterans, continues to prioritize suicide prevention research focused specifically on Veterans experiencing homelessness. Indeed, only through robust, well-designed research, supported by the VA, the National Institutes of Health, and other stakeholder agencies, can subsequent evidence-based interventions and programing be designed or tailored and then implemented in VA and non-VA settings to best meet the needs of Veterans within this high-risk population.
1. Department of Veterans Affairs. 2019 National Veteran Suicide Prevention Annual Report; 2019. Available at: www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf
. Accessed March 23, 2020.
2. Hoffberg AS, Spitzer E, Mackelprang JL, et al. Suicidal self-directed violence among homeless US veterans: a systematic review. Suicide Life Threat Behav. 2018;48:481–498.
3. Creech SK, Johnson E, Borgia M, et al. Identifying mental and physical health correlates of homelessness among first-time and chronically homeless Veterans. J Community Psychol. 2015;43:619–627.
4. Dunne EM, Burrell LE, Diggins AD, et al. Increased risk for substance use and health-related problems among homeless Veterans. Am J Addict. 2015;24:676–680.
5. Goldstein G, Luther JF, Haas GL, et al. Comorbidty between psychiatric and general medical disorders in homeless Veterans. Psychiatr Q. 2009;80:199–212.
6. O’Toole TP, Conde-Martel A, Gibbon JL, et al. Health care of homeless Veterans: why are some individuals falling through the safety net? J Gen Intern Med. 2003;18:929–933.
7. Carlson EB, Garvert DW, Macia KS, et al. Traumatic stressor exposure and post-traumatic symptoms in homeless Veterans. Mil Med. 2013;178:970–973.
8. Department of Veterans Affairs. VA/DoD Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide; 2019. Available at: www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf
. Accessed March 23, 2020.
9. Gamache G, Rosenheck R, Tessler R. Military discharge status of homeless Veterans with mental illness. Mil Med. 2000;165:803–808.
10. Curran GM, Bauer M, Mittman B, et al. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50:217–226.