Caring Letters Sent by a Clinician or Peer to At-Risk Veterans: A Randomized Clinical Trial

Abstract

Importance: Caring letters is an evidence-based suicide prevention intervention in acute care settings, but its outcomes among individuals who contact a national crisis line have not previously been evaluated.

Objective: To examine the outcomes of the Veterans Crisis Line (VCL) caring letters intervention and determine whether there are differences in outcomes by signatory.

Design, setting, and participants: This parallel randomized clinical trial compared signatories of caring letters and used an observational design to compare no receipt of caring letters with any caring letters receipt. Participants included veterans who contacted the VCL. Enrollment occurred between June 11, 2020, and June 10, 2021, with 1 year of follow-up. Analyses were completed between July 2022 and August 2023.

Intervention: Veterans were randomized to receive 9 caring letters for 1 year from either a clinician or peer veteran signatory.

Main outcomes and measures: The primary outcome measure was suicide attempt incidence in the 12 months following the index VCL contact. Incidence of Veterans Health Administration (VHA) inpatient, outpatient, and emergency health care use were secondary outcomes. All-cause mortality was an exploratory outcome. Wilcoxon rank-sum tests and χ2 tests were used to assess the differences in outcomes among the treatment and comparison groups.

Results: A total of 102 709 veterans (86 942 males [84.65%]; 15 737 females [15.32%]; mean [SD] age, 53.82 [17.35] years) contacted the VCL and were randomized. No association was found among signatory and suicide attempts, secondary outcomes, or all-cause mortality. In the analysis of any receipt of caring letters, there was no evidence of an association between caring letters receipt and suicide attempt incidence. Caring letters receipt was associated with increased VHA health care use (any outpatient: hazard ratio [HR], 1.10; 95% CI, 1.08-1.13; outpatient mental health: HR, 1.19; 95% CI, 1.17-1.22; any inpatient: HR, 1.13; 95% CI, 1.08-1.18; inpatient mental health: HR, 1.14; 95% CI, 1.07-1.21). Caring letters receipt was not associated with all-cause mortality.

Conclusions and relevance: Among VHA patients who contacted the VCL, caring letters were not associated with suicide attempts, but were associated with a higher probability of health care use. No differences in outcomes were identified by signatory.

Trial registration: isrctn.org Identifier: ISRCTN27551361.

Figure.. CONSORT Diagram of Peer-Clinician Evaluation

^aIndividuals who were unlikely to have called on their own behalf or to have contact with a Veterans Crisis Line (VCL) responder were identified as those for whom there was a record that the call from a third party caller, whose call record corresponded to an outgoing call from a responder that did not end with contact with the veteran, and whose call source was listed as an email referral, compassionate care, caregiver, social media, or assigned callback.