According to the U.S. Department of Veterans Affairs, the suicide rate for veterans was 57 percent higher in 2020 than it was for non-veteran adults. And in Oregon, that disparity was even greater. One of the ways the VA attempts to lower that rate is by training veterans’ loved ones to recognize the signs of suicidal ideation and how to respond.
A recent study from the Portland VA Health Care System and Oregon Health & Science University found that social media can be a good way to get veterans’ family and friends enrolled in that training. The study’s lead author, Dr. Alan Teo, joins us to talk about what that could mean for veteran suicide prevention.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: From the Gert Boyle studio at OPB, this is Think Out Loud, I’m Dave Miller. We turn now to the latest efforts to prevent suicide among veterans. According to the US Department of Veterans Affairs, veterans were 57% more likely to take their own lives than non-veteran adults in 2020. In Oregon, the disparity was even greater. Alan Teo is a researcher and staff psychiatrist at the VA Portland Health Care System, and an associate professor of psychiatry at OHSU. He was the lead author of a new study. It explored efforts to train veterans loved ones to recognize and respond to their suicidal thoughts. Alan Teo, welcome back.
Alan Teo: Thanks, good to join you, and appreciate you having me during Suicide Prevention Month.
Miller: And I should just say that the outside here that if you know someone, or you yourself are struggling, you can call or text 988 right now to reach the National Suicide Prevention Hotline. Alan Teo, I mentioned that veterans are more likely than non-veterans to take their own lives. Can you give us a sense for how big an issue suicide is right now among veterans?
Teo: It is a big issue. Certainly every single suicide is a loss and tragedy, but the sad fact is that we’re losing about 6,000 veterans each year by suicide. And it’s not just a veteran issue, but it’s really a population-level issue across all different groups. Suicide is a leading cause of death. And it’s preventable. It’s really preventable. We have some encouraging news. The numbers seem to be going down a little bit in the last couple of years. We don’t know exactly why. But it’s a major public health issue.
Miller: There have been some VA directed efforts to reduce or prevent suicide in recent years. Can you give a sense for what they have been, and the extent to which those may be responsible for the decline that you’ve been seeing?
Teo: Because suicide is sort of a complex issue, many different causes, many contributing factors, I think to the VAs credit, they have a whole range of programs. So for example, at each of our sites here in the Portland VA, we have suicide prevention coordinators. These are folks that make direct outreach. They do help veterans directly, but they also do a lot of education within our VA and based in the community too. And then we have a lot of systematic programs. And this is one of the benefits of the VA, they can look at what we call big data, look at the trends, and then identify target needs. And we also have things like the Veterans Crisis line, the 988 number that you mentioned is directly connected. We have trained professionals that are trained to help veterans, and are available 24/7. So really a whole range of different programs.
Miller: With this new research, you focused on so-called gatekeepers, friends or family or caretakers, as opposed to veterans themselves. Why?
Teo: Well, we know from prior research that veterans are most likely to share if they’re having a thought about suicide, or suicidal ideation as we call it, veterans are most likely to share that with a family member or a loved one. We would love for them to be able to get to the point of talking to folks like myself, a psychiatrist. But the reality is getting into the healthcare system, or there may be anxiety about accessing health care. So you can think of family and friends as the first line of defense. The other piece is family and friends, they want to play a role. We also know this from surveys, that family and friends really want to have a role to play in suicide prevention.
Miller: The VA already provides a form of online training for these people. Can you give us a sense for what it is, and how it’s currently been used?
Teo: The name of the training that we tested and evaluated in this study is called VA S.A.V.E. It stands for looking for Signs, Asking about suicidal thoughts, Validating, Encourage or Expedite a person getting into care. And so what that really encapsulates this is a set of really tangible skills that any person can learn, a gatekeeper as you describe, in terms of identifying a veteran who’s at risk for suicide, and then trying to facilitate help them get into professional care. The person being trained isn’t there to try and alleviate all the stresses that might be going on for a person. It’s really to be a facilitator and supporter and encourager.
Miller: What specifically did you set out to study in this new research, and what weren’t you studying?
Teo: Well, we were trying to actually do one of the first studies to actually evaluate this type of training. This VA SAVE training is actually used within the VA Health Care System. It’s been designed or is used for employees of the VA. That might be everyone from a groundskeeper working on the VA campus to someone at the front desk. So we were really just trying to do the first evaluation of this training that’s already being used. And then we were also trying to really focus on this online component. Can we get training out to people outside of the clinic, meet people where they are in their home, online, on social media? So we really wanted to focus on getting the training out more widely to the community.
Miller: If this is the first piece to assess the effectiveness of this training, but it’s already been rolled out for VA staff, are you saying that the VA put this module without truly knowing how effective it would be?
Teo: I think the short answer is yes. There have been a number of different iterations or versions of this training. And again, we have a lot of work that’s being done to get it out. But sometimes that happens, where there’s excitement and interest in getting things out, and the evaluation piece, the piece that a researcher like myself helps with, takes more time. And so again, we’re really excited to start to get the word out on testing this training. But you’re exactly right, Dave, we didn’t have all the data on whether it works before it was put out there.
Miller: So let’s turn to this question of how to get the word out and what has proven effective, because on social media, it seems to me you were effectively competing with this algorithmic firehose of everything, all the stuff that could be hitting people’s eyeballs based on stuff they’ve clicked before, or their purchasing habits, or their online lives. How did you try to catch people’s attention?
Teo: The first piece, you’re exactly right, we’re competing for ever shorter attention spans. And the other thing we’re trying to do is really build trust. Trusting an ad seen on Facebook or something online and the age of disinformation is challenging. So from the very get go, we partnered with people. We partnered with the VA of course, but also a nonprofit institute called Psycharmor that helped develop the training. I have veterans on my research team. And Aaron Call, who is the study coordinator for this project, is one of those veterans. And so we really incorporated veteran input sort of throughout the process of designing the study, testing these different types of social media campaign materials. We work with partners at OHSU also, because we know that sort of local, institutional credibility, for that trust piece, is really critical to have that backing.
Miller: I was struck by two very different pictures in two different ads. One had a young family, a young woman in fatigues and a man, and they’re holding a baby together between them. The other has an armored jeep driving out down the ramp of a big cargo plane. But they’re both attempting to do the same thing, to get people to sign up to then do this training module. Did you find a difference in response rates in these very different kinds of imagery?
Teo: Yeah, we saw a pretty incredible difference. Particularly that the first type of ad you described, the one where we had a picture of a family, sort of the warm, fuzzy approach you might say, was very popular. And we also specifically saw that- veterans were able to participate in this study. The only real requirement was that you were in close contact with another veteran, so of course you could be a veteran yourself and have friends and family that are veterans. However, we really found that the spouses, those types of close connections, family connections, that’s who this study particularly appealed to. And we found that many of them had unfortunately lost someone to suicide, frequently they had lost a veteran in their family to suicide. So I think there was a real motivation, a real craving for this type of training, so that people can go on and help people in their social network who happened to be veterans.
Miller: I was really struck by that last number you mentioned. Almost half, 48% of your the final participants that you got, they knew at least one veteran who had died by suicide. Was it your sense that it was that kind of experience that primed people to step up and say “I want to get more tools to prevent this?”
Teo: Exactly. People commented when we spoke to them after receiving the training, they said, “I might be at a barbecue next month, and a veteran I know may be having a lot of stress and mental health needs. Maybe that’s when I’ll need to use this training. Maybe it’ll be three months from now. The whole idea is just to be prepared, and be ready for when the need arises. And I think people who have unfortunately had suicide in their social circles know that all too well. But I think most people get this idea that you want to be prepared. In order to be prepared, you have to have some training, and it’s helpful to try this out and practice it before the real situation arises.
Miller: After a 10 week paid social media campaign, you got a total of 281 participants. I have to say, that doesn’t sound like a lot. Were you satisfied with that number?
Teo: Not to geek out on research, but this is what we call pilot trial. Many times in the mental health world, we’re talking about 10, 15, 20, 30 people. So actually having over 200 participants for this type of feasibility study that we did is actually quite large. And I credit that to the fact that we were able to having a study where people could respond to an ad online, they could receive all the training online, there was no requirement for face to face contact. And that was a benefit in terms of getting this training out and getting people to participate. So believe it or not, that’s actually a large number for a study like this.
Miller: If I understand this correctly, the main thrust of this study was to figure out the best ways to reach out to people to get them to do the training. Does that mean that the further study, to actually assess the true effectiveness of the training itself, that is still to be done?
Teo: Exactly. And we think this study positions us well to to really scale up this work, Dave, to your point again. 200 is, in the scheme of things, a small number. And I desperately want to scale this work up. But the first step was providing this proof of concept that it works, and then the next stage we would measure these specific skills. And we measure them in this study. But you need a larger sample in order to say with statistical confidence that you made a difference.
Miller: How will you do that? That seems hard. We’re not talking about having 100 people and 50 get a placebo and 50 get an antibiotic, and you see who’s going to get infected. Preventing suicide seems so much more complicated and diffuse in terms of assessing numbers. How are you going to do that?
Teo: The next step that we’re planning is to make this trial larger, but then quantify the use of these skills, we call them gatekeeper behaviors. Someone who received the training, how often how many times did they ask someone about the presence of suicidal thoughts? How many times were they worried about someone? And if they were worried about someone having suicidal thoughts, a veteran in their lives, did they make a referral? Did they connect them to the 988 phone number we talked about, as an example. So we’re going to quantify all this, and track it over months and months, and see whether there’s a sustained benefit to receiving the training, and then potentially deploying these skills in people’s real lives.
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