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Publication Briefs

Caring Letters Not Associated with Suicide Attempts Following Veterans Crisis Line Contact, But Are Associated with Higher Probability of VA Mental Healthcare Use

The suicide rate for U.S. Veterans exceeds the rate for non-Veteran adults by 57%. VA established the Veterans Crisis Line (VCL) as part of a comprehensive strategy to prevent suicide among a high-risk group of Veterans. While VCL contact is beneficial, Veterans remain at high risk of suicide for up to a year after contacting the VCL. Caring Letters is an evidence-based suicide prevention intervention consisting of multiple messages that are mailed to high-risk individuals over time, often from a clinician, to communicate that the sender cares about the recipient’s well-being. Caring Letters has never been tested with crisis line callers. This study examined the effectiveness of the VCL Caring Letters intervention and determined whether there were differences in outcomes by signatory. From June 2020–June 2021, Veterans (n=102,709; 85% male) who contacted the VCL were randomized to receive nine Caring Letters over a one-year period from a clinician or a peer Veteran the recipient had not met. The primary outcome measure was suicide attempt incidence in the 12 months following the index VCL contact. Secondary outcomes were incidence of VHA inpatient, outpatient, and emergency healthcare use. All-cause mortality was an exploratory outcome.


  • Among the Veterans in the sample, Caring Letters were not associated with suicide attempts following Veterans Crisis Line contact, but were associated with higher probability of VHA outpatient and inpatient mental healthcare use.
  • There was no association among clinician vs. peer Veteran signatory and suicide attempts; VHA inpatient, outpatient, and emergency healthcare use; or all-cause mortality.


  • Caring Letters may support access to care for high-risk Veterans who contact the VCL.


  • The COVID-19 pandemic might have affected the likelihood of Veterans contacting the VCL and the outcomes.
  • Use of healthcare records to ascertain suicide attempts is a common method but may underestimate attempts.

This study was funded by QUERI. Dr. Reger is with HSR’s Center of Innovation for Veteran-Centered and Value Driven Care. Dr. Landes is with HSR’s Center for Mental Healthcare and Outcomes Research (CeMHOR) and Behavioral Health QUERI. Dr. Garrido is with the Partnered Evidence-Based Policy Resource Center (PEPReC) and HSR’s Center for Healthcare Organization and Implementation Research (CHOIR).

Reger MA, Legler A, Lauver MG, Tenso K, Manchester C, Griffin C, Strombotne KL, Landes SJ, Porter S, Bourgeois J, and Garrido MM. Caring Letters Sent by a Clinician or Peer to At-Risk Veterans. JAMA Network Open. April 29, 2024;7(4):e248064.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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