Caring letters show mixed results for veterans in crisis

Caring letters did not reduce the occurrence of suicide attempts among veterans who called a crisis hotline, a large study has found. But the letters, sent for one year after the former military service members reached out for help, did spur callers to use Veterans Health Administration mental health resources.

The mixed results of the clinical trial, conducted in collaboration with staff of the Veterans Crisis Line, underscore the importance of a comprehensive public health approach to suicide prevention in the veteran community.

“This is a critical challenge in our broader society and one that the VA is trying to address,” said lead author Mark Reger, professor of psychiatry at the University of Washington School of Medicine and chief of psychology services at VA Puget Sound Health Care System. “Suicide rates among veterans have been rising. I do clinical work on the mental health inpatient unit and we see a lot of suicidal veterans.”

The results of the clinical trial of more than 102,000 crisis- line callers appeared April 29 in JAMA Network Open. Reger noted that prior research showed that a call to the Veterans Crisis Line is helpful, but the callers appeared to remain at risk for suicide for at least a year afterward.

Veterans struggle with a variety of issues, Reger said: relationship problems, significant mental health challenges and other life stressors that can be exacerbated by their experiences during military service. The suicide rate among veterans is 72% higher than that of nonveteran adults in the United States. More than 6,300 former military members died by suicide in 2021, the most recent year for which statistics are available. 

“It's a very complex problem,” Reger said.

Caring letters were developed by World War II veteran-turned-psychiatrist Jerome Motto. He remembered the therapeutic effect of receiving letters while overseas, even from people he did not know well. The messages are an evidence-based suicide-prevention intervention, often simple postcards signed by a clinician. They are designed to foster caring connections and remind high-risk individuals that help and health care resources are available. 

The researchers said this is the first major evaluation of caring letters in a crisis line setting. Previous caring- letters studies not associated with crisis lines showed mixed results for reducing suicide attempts. Reger and his coauthors had hoped to see a stronger positive signal, but the data showed the letters had no impact on suicide attempts. 

“The military culture emphasizes things like strength, courage, sucking it up and driving on,” Reger said. “These kinds of themes really help them in a deployment environment. But when they come home, they find that those might not help them as much — especially when it comes to asking for help. 

“We really want to get the word out that asking for help is actually a sign of strength and it takes a lot of courage to do that.” 

Veterans who are in crisis or having thoughts of suicide, as well as people who know a veteran in crisis, may call the Veterans Crisis Line for confidential support. The line is staffed 24/7. Dial 988, then press 1 via phone or send a text message to 838255. Support is also available via online chat.

This study was funded by a VA Quality Enhancement Research Initiative and the Veterans Crisis Line. They will soon begin a study to see if the intervention reduced suicide mortality.

The authors’ conflict-of-interest statements are in the published paper, which will be provided to journalists upon request.

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