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Background: Rates of suicide remain elevated among U.S. Veterans and have increased disproportionately among Asian American and Pacific Islander (AAPI) Veterans. Knowledge is limited regarding suicide prevention considerations for clinicians working with AAPI Veterans, yet culturally responsive strategies tend to be most effective. To address this gap, we sought to elucidate subject matter experts' perspectives regarding suicide prevention considerations for AAPI Veterans., Methods: Qualitative interviews were conducted with 14 key informants (e.g., clinicians, researchers) in 2023 to understand their experiences with, and recommendations for, preventing suicide among AAPI Veterans in the Continental U.S. Interview transcripts were analyzed through thematic analysis, with an inductive approach., Results: Key informants discussed the heterogeneity of the AAPI population and emphasized the need to balance cultural sensitivity and cultural humility in suicide prevention with AAPI Veterans. Fear of bringing shame and dishonor upon one's family was described as a factor which may prevent AAPI Veterans from disclosing mental health concerns and suicide risk and which may prevent them from accessing healthcare services for mental health and suicidality. Suicide risk among AAPI Veterans was viewed as being shaped by shame and the centrality of the family-collective, with family conferring both protection against and risk for suicide. Cultural norms and beliefs regarding suicide were considered pertinent to suicide among AAPI Veterans and included beliefs about perseverance in coping with distress to permittance of suicide in specific circumstances. Somatic idioms were described as a means by which AAPI Veterans may communicate distress and suicidality, with key informants discussing how this may impact treatment and outreach., Conclusion: Key informant interviews provided crucial insights into cultural factors salient to conceptualizing and addressing AAPI Veterans' risk for suicide. These findings can be utilized to inform tailored suicide prevention for this population, with emphasis on addressing mental health stigma, considering somatic idioms of distress, and considering the role of family in suicide risk and prevention., Competing Interests: Declarations. Ethics approval and consent to participate: The Colorado Multiple Institutional Review Board approved this study (21-4023). Informed consent was obtained prior to initiating study procedures, with verbal communication of consent. Consent for publication: Not applicable. Competing interests: All authors report grant funding from the VA. ERP, CMR, RH and LLM also report funding from the Department of Defense. RH reports funding from the state of Colorado. LLM reports funding from the Face-the-Fight Initiative., (© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Competing Interests: None of the authors identify a conflict of interest.

Objective: Women represent 15% of veteran callers to the Veterans Crisis Line (VCL); there has been little research identifying the experiences and needs of women veterans who use the VCL. The objective of this study was to identify women veterans' experiences with and recommendations for strengthening VCL services for women., Method: We conducted qualitative interviews with 26 women veterans across the United States who had contacted the VCL in the preceding year. Interviews were conducted by telephone in 2022 and were audio recorded and transcribed. A team-based content analysis approach was used to identify participants' concerns around contacting the VCL and recommendations for strengthening the service., Results: Interviews revealed women veterans' concerns with regard to contacting the VCL related to responder gender, appropriateness of VCL services for veterans not at imminent risk for suicide, and potential consequences of contacting the VCL. Key recommendations included letting veterans select the gender of the responder who takes their call, providing more information to potential callers about what to expect from VCL calls, and raising awareness about and maintaining options for caller anonymity., Conclusions: This study uniquely focused on women veterans' experiences and perspectives, in their own voices. Findings point to trauma-informed approaches supporting women veteran callers to the VCL and may also hold implications for other similar crisis hotline services., (Published by Elsevier Inc.)

Objective: Women are a minority veteran subpopulation experiencing particular risk for suicide and facing distinct challenges in accessing Veterans Health Administration (VHA) care. As part of efforts to enhance suicide prevention, the VHA established Suicide Prevention Coordinators (SPC) as clinicians who work exclusively to connect high-risk veterans to the scope of VHA's services. To understand the experiences of women veterans with suicide risk who access care, this study presents findings from qualitative interviews with SPCs regarding the care needs, preferences, and concerns of women veterans who utilize VHA for enhanced suicide-related care., Methods: We conducted qualitative interviews with 20 SPCs from 13 VAMCs around the United States. We specifically asked SPCs to share perspectives on women veterans' barriers to accessing care and their recommendations to improve suicide prevention for this subpopulation. We conducted a thematic content analysis to extract key themes., Results: SPCs revealed that women veterans opt to avoid VHA due to prior negative experiences, often related to provider sensitivity to women's issues. Safety was another key concern, specifically related to feeling unwelcome or intimidated in the male dominated veteran community. Key provider recommendations include increasing the availability of gender-sensitive providers and making changes to the physical spaces of the VHA to better facilitate women veterans' access to care., Conclusions: SPCs underscored the importance of comfort and relatability between women patients and providers, especially in relation to enhanced care for suicide risk. This study presents important evidence in support of enhancing suicide prevention by better engaging women veterans in care that is more inclusive and more sensitive to their experiences and identity, in and outside VHA., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2023. Published by Elsevier Inc.)

Objective: The Veterans Health Administration (VHA) recognizes peer support as an underused intervention in suicide prevention. PREVAIL is a peer-based suicide prevention intervention that was designed and piloted with non-veteran patients recently hospitalized for suicidal thoughts or behaviors. The purpose of this study was to elicit veteran and stakeholder feedback to inform the adaptation of PREVAIL for piloting with veterans flagged for high suicide risk., Methods: Semi-structured interviews were conducted with multiple stakeholders from a VHA medical center in the northeast. Interviews focused on the perceived benefits and concerns of peer specialists directly addressing suicide risk with veterans. Interviews were recorded, transcribed, and analyzed using rapid qualitative analysis., Results: Interviewees included clinical directors (n = 3), suicide prevention coordinators (n = 1), outpatient psychologists (n = 2), peer specialists (n = 1), and high-risk veterans (n = 2). Overall, peer specialists were viewed as possessing many distinct strengths in engaging and helping high-risk veterans as part of a team approach. Concerns included liability, adequate training, clinical supervision and support, and self-care for peer specialists., Conclusions: Findings indicated support and confidence that peer support specialists would be a valuable addition and could help fill existing gap in VHA's suicide prevention efforts., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The mental health impacts of the COVID-19 pandemic have been widely felt among already vulnerable populations, such as U.S. military veterans, including a heightened risk for depression and suicidal ideation. Support hotlines such as the Veterans Crisis Line (VCL) took a central role in addressing various concerns from callers in distress; research has yet to examine the concerns of veterans who used the VCL during the early months of the pandemic., Methods: A mixed-methods analysis of characteristics of veteran outreach to the VCL during the first year of the COVID-19 pandemic in the United States was conducted on 342,248 calls during April-December 2020; 3.8% (N=12,869) of calls were coded as related to COVID-19. Quantitative examination was conducted regarding COVID-19-related reasons for contact, suicide risk screens, and caller concerns; 360 unique calls with synopsis notes that included a COVID-19 flag were qualitatively analyzed., Results: Quantitative analysis of the calls with a COVID-19 flag revealed mental health concerns, loneliness, and suicidal thoughts as top reasons veterans contacted the VCL during the pandemic. Qualitative analysis identified specific economic and mental health concerns, including negative impacts on income and housing, increased feelings of depression or anxiety, and pandemic-specific concerns such as testing and vaccine availability. Disrupted access to resources for coping, including support groups or gyms, had negative perceived impacts and sometimes exacerbated preexisting problems such as substance abuse or depression., Conclusions: These findings emphasize the role of VCL as providing general support to veterans experiencing loneliness and supplying assistance in coping with pandemic-related distress.

Background: Suicide is a major public health crisis within the US military veteran community, with distinct gender differences in suicide risk and behavior. The Veterans Crisis Line (VCL) is a component of the Veterans Health Administration (VHA) suicide prevention program; through VCL, veterans may be referred to a VHA Suicide Prevention Coordinator (SPC) to arrange follow-up care. Research shows that engagement with an SPC is a strong protective factor in reducing veteran suicide risk., Methods: We evaluated SPC referral acceptance and assessed correlates of SPC referral decline using VCL administrative data for contacts: (1) made between January 1, 2018, through December 31, 2019; (2) by veterans contacting VCL on their own behalf; (3) with gender identified; and (4) current thoughts of suicide. Then, among a subsample of 200 veterans, evenly distributed by gender, we examined data from call synopsis notes to identify reasons given for veterans declining an SPC referral., Results: We found it was generally callers rated as lower risk by responders, and callers with loneliness as a reason for contacting VCL, who more frequently declined the SPC referral. An analysis of reasons given for declining SPC referral found that concerns with/about Veterans Affairs care were a key concern, particularly among women veterans articulating specific negative care experiences. Other reasons for referral decline included managing the veteran's needs directly on the call or via alternative resources., Conclusion: The VCL as an intervention provides an important opportunity to re-engage vulnerable veterans into care, one that may be more challenging for women veterans., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare characteristics of calls to the Veterans Crisis Line (VCL) by caller gender and identify potentially unique needs of women callers., Method: Retrospective review of clinical data collected during VCL calls, comparing call characteristics between women and men veteran callers., Results: The data included 116,029 calls by women veterans and 651,239 calls by men veterans between January 1, 2018-December 31, 2019. Timing (hour/day/season) of VCL calls was similar between women and men callers. We observed gender differences in reason for call, with the most salient differences in reasons related to interpersonal violence, including sexual trauma (e.g., military sexual trauma as reason for call - prevalence ratio (PR) for women vs. men = 9.13, 95% CI = 8.83, 9.46). Women callers were also more likely than men callers to screen positive for suicide risk (PR = 1.28, 95% CI = 1.26, 1.29), receive a higher suicide risk assessment rating (PR = 1.05, 95% CI = 1.02, 1.07), and be referred to a VA Suicide Prevention Coordinator for follow-up (PR = 1.09, 95% CI = 1.09, 1.11)., Conclusions: Analysis of VCL call data indicated both similarities and differences across genders in call characteristics, including interpersonal relationships and experiences of abuse and assault as particularly salient factors prompting women veterans' calls to VCL. This study also suggests the presence of increased suicide risk among women versus men veteran VCL callers., (Published by Elsevier Inc.)

As a therapeutic practice of care, "watchfulness" (Garcia 2010) implies a vigilant responsibility and constant mindfulness of others; in Hawaii, this is captured in the concept of aloha. This article explains how watchful care with aloha is discussed and mobilized in community suicide prevention in Hawaii. Rates of suicidality and suicide attempts in the state are high, among young people in particular. My ethnographic research follows a network of workers and volunteers as they incorporate local understandings of aloha into suicide prevention outreach. Following a history of aloha's meanings and (mis)uses in and beyond Hawaii, I draw on ethnographic examples to reveal how care with aloha prioritizes personal connection and individuality, rather than being rhetorically detached or "anonymous" (Stevenson 2014). But as my central vignettes reveal, there are difficulties in the implementation of this kind of watchful care, which ultimately question its utility in suicide prevention., (© 2020 by the American Anthropological Association.)

Background: The impacts of opioid use disorder and opioid-involved overdose are known, but less is known about the contexts in which people first misuse opioids, and the motivations for continued misuse. Methods: In-depth interviews with 26 individuals in Allegheny County, Pennsylvania with current or past histories of opioid misuse were conducted. Narratives were analyzed to understand the circumstances and influences contributing to initial and continued misuse of opioids. Results: Participants described social and familial contexts that normalized or accepted opioid misuse-this often included their own use of other illicit substances prior to initiating opioids. Participants also described initial use of opioids as related to efforts to cope with physical pain. They also described recognizing and then seeking psychological/emotional benefits from opioids. All three of these themes often overlapped and intersected in these stories of starting opioid misuse. Conclusions: Opioid misuse stemmed from complex interacting influences involving coping with physical and psychological pain, perception that opioids are needed to feel "normal", and acceptance or normalization of opioid use. This suggests a multi-pronged approach to both prevention and treatment are needed.