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Background: This study reports on gender differences in psychosocial symptoms and suicidal thoughts and behaviors from the first longitudinal, national survey of veterans with a recent nonfatal suicide attempt to inform women-tailored suicide prevention., Methods: We recruited all female veterans with a documented nonfatal suicide attempt between October 2018 and September 2019 and a stratified matched sample of males. Surveys were administered at baseline, month 6, and month 12; 968 veterans completed the baseline survey with valid gender data. Surveys assessed psychosocial constructs, suicidal ideation severity, and suicidal behavior. Administrative datasets provided healthcare and suicide attempt data during the one year follow up., Results: Women retained higher social rejection and institutional betrayal, and lower self-compassion and autonomy than men over follow up. Higher overall self-compassion was associated with lower baseline suicide ideation for both women and men; however, this association was stronger for women (Δ = -0.19; 95 % CI = -0.31, -0.07; d = -0.15). Individuals with higher overall psychological distress had greater odds of a subsequent suicide attempt (AOR = 2.20, 95 % CI = 1.56, 3.11). Social rejection had the strongest association with worsening psychological distress, both within individuals (b = 0.18; 95 % CI = 0.14, 0.23; d = 0.23) and between individuals (b = 0.07; 95 % CI = 0.04, 0.10; d = 0.09)., Limitations: Results may not generalize beyond a VHA-utilizing veteran population., Conclusions: Findings from this study inform potential therapeutic targets and topics for future research on tailoring suicide prevention for women veterans. While all veterans may need support reducing distress, women may need additional support in multiple other areas., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Published by Elsevier B.V.)

Objective: While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings., Method: Qualitative thematic analysis using a conventional/directed hybrid approach., Results: A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options., Conclusions: While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care., (Published by Elsevier Inc.)

Importance: Psychiatric hospitalization is the standard of care for patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk. However, the effect of hospitalization in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous., Objectives: To estimate the association of psychiatric hospitalization with subsequent suicidal behaviors using observational data and develop a preliminary predictive analytics individualized treatment rule accounting for heterogeneity in this association across patients., Design, Setting, and Participants: A machine learning analysis of retrospective data was conducted. All veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from January 1, 2010, to December 31, 2015, were included. Data were analyzed from September 1, 2022, to March 10, 2023. Subgroups were defined by primary psychiatric diagnosis (nonaffective psychosis, bipolar disorder, major depressive disorder, and other) and suicidality (SI only, SA in past 2-7 days, and SA in past day). Models were trained in 70.0% of the training samples and tested in the remaining 30.0%., Exposures: Psychiatric hospitalization vs nonhospitalization., Main Outcomes and Measures: Fatal and nonfatal SAs within 12 months of ED/UC visits were identified in administrative records and the National Death Index. Baseline covariates were drawn from electronic health records and geospatial databases., Results: Of 196 610 visits (90.3% men; median [IQR] age, 53 [41-59] years), 71.5% resulted in hospitalization. The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, -0.1%; 95% CI, -0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs. For patients with SA in the past day, hospitalization was associated with risk reductions ranging from -6.9% to -9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates., Conclusions and Relevance: The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations.

Universal screening for suicidal ideation in primary care and mental health settings has become a key prevention tool in many healthcare systems, including the Veterans Healthcare Administration (VHA). In response to the coronavirus pandemic, healthcare providers faced a number of challenges, including how to quickly adapt screening practices. The objective of this analyses was to learn staff perspectives on how the pandemic impacted suicide risk screening in primary care and mental health settings. Forty semi-structured interviews were conducted with primary care and mental health staff between April-September 2020 across 12 VHA facilities. A multi-disciplinary team employed a qualitative thematic analysis using a hybrid inductive/deductive approach. Staff reported multiple concerns for patients during the crisis, especially regarding vulnerable populations at risk for social isolation. Lack of clear protocols at some sites on how to serve patients screening positive for suicidal ideation created confusion for staff and led some sites to temporarily stop screening. Sites had varying degrees of adaptability to virtual based care, with the biggest challenge being completion of warm hand-offs to mental health specialists. Unanticipated opportunities that emerged during this time included increased ability of patients and staff to conduct virtual care, which is expected to continue benefit post-pandemic., Competing Interests: The authors have declared that no competing interests exist.

Background: Recent data show many veterans who die by suicide are not currently engaged in mental health care. Veterans frequently use the Internet for health information and may look online for community resources when in distress. However, little is known about their design characteristics. Aim: To evaluate the design and content of community, veteran suicide prevention websites. Method: Community websites focused on veteran suicide prevention were gathered through Internet searches using standardized search terms. Websites that met the inclusion criteria ( n = 9) were evaluated for adherence to suicide safe messaging, usability, readability, and credibility heuristics. Interrater reliability was evaluated using kappa statistics. Descriptive statistics were used to describe website features. Results: Community websites tended to provide help-seeking information, safe messaging, and community activities. However, no websites provided information on lethal means safety or references to signal credibility. Limitations: The sample was small and only included English-language websites, and focused on veteran-oriented, community websites. Conclusion: Community suicide prevention websites focused on veterans could be improved through increased readability, credibility, and provision of lethal means safety information.

In this study, we examined the indirect effect of the Virtual Hope Box (VHB) smartphone application on suicidal ideation, mediated through coping self-efficacy. A total of 117 veterans with suicidal ideation completed measures on coping self-efficacy and suicidal ideation at baseline and weeks 3, 6, and 12. Participants were randomly assigned to either the VHB or enhanced treatment as usual (eTAU) condition. Parallel process growth curve modeling (-0.20 [95% CI = -0.44, 0.00]) and auto-regressive modeling (-0.12 [95% CI = -0.35, -0.01]) revealed that a higher rate of change in coping self-efficacy in the VHB group was associated with a decrease in suicidal ideation severity, as compared to the eTAU group. Findings suggest that coping self-efficacy may be one mechanism by which the VHB operates to help reduce suicidal ideation. More broadly, the role of coping self-efficacy in reducing suicidal ideation is worthy of future study.

This qualitative study explores the relationship between veterans' spirituality/religion and suicide ideation and attempts. Qualitative semi-structured interviews were conducted with 30 veterans who either endorsed chronic suicidal ideation or had made suicide attempt(s). Interviews explored the bi-directional relationship between spirituality/religion (e.g., beliefs, practices, and experiences), and suicide ideation and behaviors. Interviews were analyzed using thematic analysis. Veterans' responses indicate that spirituality/religion can discourage or permit suicidal ideation, help in coping with ideation, and facilitate meaning making and coping in the presence of self-perceived suffering. Veterans who survived a suicide attempt explored the impact of their spirituality/religion on their recovery. Findings highlight a complex and diverse relationship between spirituality/religion and suicidality. These findings may inform further research on treatment strategies that assess the function of spirituality/religion, and incorporate protective aspects of spirituality/religion into mental health treatment.

Background: Although the substantial influence of social relationships on health is well-known, studies that concurrently examine the influence of varying dimensions of social connectedness on major depression are more limited. This study's aim was to determine to what degree several facets of social connectedness (number of confidants, social support, interpersonal conflict, social norms, and loneliness) are correlated with depression-related outcomes., Methods: Participants were primary care patients (n = 301) with probable major depression at a Veterans Health Administration hospital and its satellite clinics. Social connectedness was primarily measured using multi-item instruments from the NIH Toolbox of Adult Social Relationship Scales. Primary outcomes were clinical symptoms (depression and suicidal ideation) and secondary outcomes were self-reported health-related behaviors (medication adherence, patient activation, and help-seeking intentions)., Results: In multivariate models adjusting for potential confounders and other facets of connectedness, loneliness was associated with higher levels of depression and suicidal ideation, as well as lower patient activation and help-seeking intentions. Social support and social norms about depression treatment were each associated with higher patient activation and help-seeking intentions. Social connectedness was not associated with medication adherence., Limitations: The limitations of this study are primarily related to its cross-sectional survey design and study population., Conclusions: Multiple aspects of social connectedness are associated with depression outcomes among military veterans with depression. Loneliness may represent the most important component of connectedness, as it is associated with depression severity, suicidality, and health-related behaviors., (Published by Elsevier B.V.)

Objective: Little is known about patient outcomes following discontinuation of opioid therapy, which may include suicidal ideation (SI) and suicidal self-directed violence (SSV). The purpose of this study was to examine correlates of SI and non-fatal SSV in a sample of patients discontinued from long-term opioid therapy (LTOT)., Method: Five hundred-nine Veterans Health Administration (VHA) patients whose clinicians discontinued them from LTOT were selected from a national cohort of VHA patients who discontinued opioids in 2012. The sample comprised patients with a substance use disorder and matched controls. Patient electronic health records were manually reviewed to identify discontinuation reasons and the presence of SI or SSV in the 12months following discontinuation., Results: Forty-seven patients (9.2%) had SI only, while 12 patients (2.4%) had SSV. In covariate-adjusted logistic regression models, mental health diagnoses associated with having SI/SSV included post-traumatic stress disorder (aOR=2.56, 95% CI=1.23-5.32) and psychotic disorders (aOR=3.19, 95% CI=1.14-8.89). Other medical comorbidities, substance use disorder and pain diagnoses, opioid dose, and benzodiazepine prescriptions were unrelated to SI/SSV., Conclusions: Among patients with a substance use disorder and matched controls, there are high rates of SI/SSV following opioid discontinuation, suggesting that these "high risk" patients may require close monitoring and risk prevention., (Published by Elsevier Inc.)

Curiosity, the tendency to engage in novel and challenging opportunities, may be an important source of resilience for those at risk for suicide. We hypothesized that curiosity would have a buffering effect against risk conferred by multiple sources of distress, whereby curiosity would be associated with reduced suicidal ideation and increased coping efficacy. As part of a larger intervention trial designed to improve coping skills and reduce suicidal ideation, 117 military veterans with suicidal ideation completed measures of curiosity and distress (perceived stress, depression, anxiety, and sleep disturbances) at baseline, and completed measures of suicidal ideation and coping efficacy (to stop negative thoughts, to enlist support from friends and family) at baseline and 3-, 6-, and 12-week follow up. Growth curve models showed that curiosity moderated the association between distress and suicidal ideation at baseline and that curiosity moderated the association between distress and increased coping efficacy to stop negative thoughts over time. Findings suggest that curiosity may buffer against the effect of heightened levels of distress on suicidal ideation and help facilitate stronger gains in coping efficacy over time. Additional work should further examine the role of curiosity as a protective factor for veterans with suicidal ideation., (Published by Elsevier B.V.)

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow-up (n = 168; 57%). Fifty-three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide., (© Published 2016. This article is a U.S. Government work and is in the public domain in the USA.)

Objective: We describe Veterans Affairs (VA) primary care received by veterans with mental health symptoms in the year prior to suicide to identify opportunities to improve care., Method: Death certificate data from 11 states were linked to VA national patient care data for veterans who died by suicide in 2009 and had received VA care. We identified 118 age-, sex- and clinician-matched case-control pairs (suicide decedents and living controls) with mental health symptoms. Using McNemar's chi-square and paired t tests, we compare primary care follow-up received during the year prior to death., Results: Cases and controls received similar primary care clinician follow-up and treatment for mental health symptoms. Cases were less likely than controls to fill 90 or more total days of an antidepressant during the year (P=.02), despite no differences in prescription orders from clinicians (P=.05). Cases and controls were equally likely to fill 90 or more consecutive days of an antidepressant (P=.47). Across both groups, 48% (n=113) received assessment for suicidal ideation in primary care., Conclusion: We identified two areas to improve primary care for veterans at risk for suicide: monitoring antidepressant treatment adherence and improving suicidal ideation assessment and follow-up for veterans with mental health symptoms., (Published by Elsevier Inc.)

We sought to understand Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans' experiences with suicidal ideation. Semi-structured interviews with 34 OEF/OIF veterans addressed circumstances leading up to disclosure of suicidal ideation during brief clinical assessments. We used an iterative, inductive and deductive thematic analysis approach. Results revealed three pervasive, persistent domains that reinforce the uniqueness of veteran suicidal thoughts: military culture, difficult deployment experiences, and postdeployment adjustment challenges. Within postdeployment, we identified four themes that serve as intervention targets: adjusting to civilian culture, changes to sense of self, feeling overwhelmed by stressors, and lacking life purpose or meaning., (© Published 2014. This article is a U.S. Government work and is in the public domain in the USA.)

We evaluated the impact of brief structured suicidal ideation (SI) assessments on mental health care among new-to-care Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans. National datasets provided military, demographic, and clinical information. For all new-to-care OEF/OIF veterans administered depression screens (PHQ-2: Patient Health Questionnaire-2) and structured SI assessments in primary care or ambulatory mental health settings of three Veterans Affairs (VA) Medical Centers between April 2008 and September 2009 (N=465), generalized estimating equations were used to examine associations between SI and number of subsequent-year specialty mental health visits and antidepressant prescriptions. Approximately one-third of the veterans reported SI. In multivariate models, PTSD and anxiety diagnoses, severe depression symptoms, being married, and SI assessment by a mental health clinician were associated with more mental health visits in the subsequent year. Depression, PTSD, and anxiety diagnoses, and SI assessment by a mental health clinician were associated with receiving antidepressants. Presence of SI did not significantly affect subsequent year mental health utilization when adjusting for diagnostic and clinician variables, but inaugural visits involving mental health clinicians were consistently associated with subsequent mental health care., (Published by Elsevier Ireland Ltd.)

Objective: To examine primary care clinician actions following positive suicide risk assessments administered to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans., Methods: We identified OEF/OIF veterans with positive templated suicide risk assessments administered in primary care settings of three Veterans Affairs (VA) Medical Centers. National VA datasets and manual record review were used to identify and code clinician discussions and actions following positive assessments. Bivariate analyses were used to examine relationships between patient characteristics and discussions of firearms access and alcohol/drug use., Results: Primary care clinicians documented awareness of suicide risk assessment results for 157 of 199 (79%) patients with positive assessments. Most patients were assessed for mental health conditions and referred for mental health follow-up. Clinicians documented discussions about firearms access for only 15% of patients. Among patients whose clinicians assessed for substance abuse, 34% received recommendations to reduce alcohol or drug use. Depression diagnoses and suicidal ideation/behavior severity were significantly associated with firearms access discussions, while patient sex, military service branch, and substance abuse diagnoses were significantly associated with recommendations to reduce substance use., Conclusion: Greater efforts are needed to understand barriers to clinicians' assessing, documenting and counseling once suicidal ideation is detected, and to develop training programs and systems changes to address these barriers., (Published by Elsevier Inc.)

Background: We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs' (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder., Methods: We retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers' primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments., Results: Of 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively)., Limitations: Study findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment., Conclusions: SI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden., (Published by Elsevier B.V.)

Objectives: We describe processes, rates, and patient and system correlates of brief structured assessments (BSAs) for suicidal ideation among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with positive depression screens., Methods: Electronic Veterans Affairs (VA) medical record and Department of Defense data were used to identify individual-level and BSA-process variables for 1662 OEF/OIF veterans at three VA Medical Centers., Results: Overall, 1349/1662 (81%) veterans received BSAs for suicidal ideation within 1 month of depression screening; 94% of BSAs were conducted within 1 day. Stratified analyses revealed significant intersite differences in veteran demographics, instruments used, clinical setting and staff performing assessments, and correlates of assessment completion. At two sites, men were more likely to be assessed than women [odds ratio (OR)=2.15 (95% confidence interval {CI}=1.06-4.38) and 3.14 (CI=1.27-7.76)]. In a combined model adjusted for intrasite correlation, assessment was less likely during months 8-12 and 13-18 of the study period [OR=0.39 (CI=0.28-0.54) and OR=0.48 (95% CI=0.35-0.68), respectively] and more likely to occur among veterans receiving depression or posttraumatic stress disorder diagnoses on the day of depression screening [OR=1.83 (CI=1.36-2.46) and OR=1.50 (CI=1.13-1.98), respectively]., Conclusions: Most veterans with positive depression screens receive timely BSAs for suicidal ideation. Processes used for brief assessment for suicidal ideation vary substantially across VA settings., (Published by Elsevier Inc.)

Background : In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings. Objective: The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program. Design: Mixed methods; survey and qualitative interviews. Participants: Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews. Main Measures: The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID. Key Results: Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered. Conclusions: Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts. [ABSTRACT FROM AUTHOR]

Mental health applications (apps) can improve access to evidence- based, mental health strategies. This study evaluated predictors of use for the Virtual Hope Box (VHB), a smartphone app designed to enhance coping among high-risk mental health populations. We also explored the impact of usage on health outcomes. We analyzed data drawn from the treatment arm of a randomized clinical trial of the VHB (n=58). Veterans at high risk of suicide used the app over 12 weeks and completed psychosocial assessments throughout the study. We received usage data from each participant's smartphone. We then used negative binomial regression to evaluate demographic and clinical predictors of usage and generalized estimating equations to explore the longitudinal association between usage and psychosocial outcomes. The most commonly used subcomponents were designed to provide distractions and reminders of sources of meaning. Lower levels of usage were associated with younger and having a 2-year college degree or higher. Exploratory findings suggested a possible relationship between usage and protective factors. Certain subgroups had lower VHB usage. The findings suggest usage may be associated with changes in health outcomes. Future studies should recruit larger, more diverse samples to further explore relationships between usage and demographic predictors. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to assess the impact of the Virtual Hope Box (VHB), a smartphone app to improve stress coping skills, suicidal ideation, and perceived reasons for living among patients at elevated risk of suicide and self-harm.Methods: The authors conducted a parallel-group randomized controlled trial with two groups of U.S. service veterans in active mental health treatment who had recently expressed suicidal ideation. Between March 2014 and April 2015, 118 patients were enrolled in the study. Participants were assigned to use the VHB (N=58) or to a control group that received printed materials about coping with suicidality (N=60) to supplement treatment as usual over a 12-week period. Three measures-the Coping Self-Efficacy Scale, Beck Scale for Suicidal Ideation, and Brief Reasons for Living Inventory-were collected at baseline (before randomization) and three, six, and 12 weeks. Secondary measures-the Interpersonal Needs Questionnaire, Perceived Stress Scale, and Columbia-Suicide Severity Rating Scale-were collected at baseline and 12 weeks.Results: VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (Coping Self-Efficacy Scale) at three (b=2.41, 95% confidence interval [CI]=.29-4.55) and 12 weeks (b=2.99, 95% CI=.08-5.90) compared with the control group. No significant advantage was found on other outcome measures for treatment augmented by the VHB.Conclusions: The VHB is a demonstrably useful accessory to treatment-an easily accessible tool that can increase stress coping skills. Because the app is easily disseminated across a large population, it is likely to have broad, positive utility in behavioral health care. [ABSTRACT FROM AUTHOR]

The article offers information on the health coaching, a patient-centered modality that focuses on personal goals, values, and strengths to facilitate well-being. It mentions the feasibility and acceptability of a telephone-delivered health coaching intervention among veterans with suicidal ideation; and also mentions the use of health coaching among clients with mental health conditions has examined the use of coaching among patients with suicidal ideation.

Rationale: The rate of suicide mortality among women is increasing in the United States (U.S.), especially among military veterans. Prior research suggests that important gender differences in suicide risk exist, but not enough is known to tailor prevention approaches by gender. Objective: The goal of this study is to understand gender differences in the development of suicidal behaviors (suicide risk) among U.S. veterans to inform future research and gender-tailored prevention efforts. Methods: Using a modified grounded theory approach, this qualitative study interviewed 50 (25 men, 25 women) U.S. veterans who had made a recent (prior 6 months) suicide attempt. Veterans were recruited from Veterans Health Administration (VHA) healthcare facilities across the U.S. Semi-structured, hour-long interviews examined participants' experiences with military service, suicidal thoughts and attempts, and healthcare following their attempt. Results: The analysis revealed two gendered narratives of suicidal thoughts and attempts that incorporated the primary themes of self-concept, social power, relationships, coping, and stress. When discussing reasons for their suicide attempts, women discussed negative self-evaluative processes describing themselves as, "shameful," "tainted," and "worthless," whereas men discussed becoming overwhelmed, and recalled thinking, "it just wasn't worth it," "I've had enough," and, "screw this." Conclusions: This study provides an in-depth, nuanced understanding of the gender differences in suicide risk among veterans and suggests several ways in which future work may address gender-tailored suicide prevention efforts. Specifically, women veterans may benefit from methods to increase self-worth through positive social relationships, while men veterans may benefit from methods that increase their sense of purpose in life and help them achieve their ideal selves through successful experiences. • Gender differences exist in the development of suicidal behavior among veterans. • Women veterans describe feeling low self-worth and devalued by others. • Men veterans relay frustration with the external world and their lack of success. • Findings suggest the importance of considering gender in suicide prevention efforts. [ABSTRACT FROM AUTHOR]