Updated 2019 VA/DoD Clinical Practice Guidelines for Managing Suicide Risk

A workgroup convened by the US Department of Veteran Affairs and US Department of Defense released updated joint clinical practice guidelines with the goal of reducing the incidence of suicide through screening and evaluation of patients identified with elevated risk.

Based on emerging new evidence and multidisciplinary consensus, a workgroup convened by the US Department of Veteran Affairs (VA) and US Department of Defense (DoD) released joint clinical practice guidelines updated for the assessment and management of patients at risk for suicide. The goal of the recommendations was to reduce incidence of suicide through screening and evaluation of patients identified with elevated risk. This report was published in Annals of Internal Medicine.

A multidisciplinary guideline panel drafted key questions focused on evaluation and treatment strategies for managing suicide risk for VA and DoD patients and performed a systematic review of literature relevant to the questions. The panel created algorithms based on current best practices and used these to develop recommendations, which were rated according to the Grading of Recommendations Assessment, Development and Evaluation methodology.

Recommendations for Screening and Evaluation

The VA/DoD recommends the use of a validated screening tool to identify patients at risk for suicidal behaviors. They further endorse the use of Patient Health Questionnaire-9 item 9 in the selection of a universal screening tool, as responses predicted both suicide attempts and death within a year of administration.

To avoid the risk for misclassification, clinicians should not rely on any single instrument or method of evaluation; the VA/DoD recommends using several risk assessment tools, including structured clinical interviews, self-report measures, or predictive analytic models.

Currently, there is no reliable tool to stratify patients according to their level of suicide risk; the VA/DoD does not recommend for or against the use of risk stratification in this patient population.

Recommendations for Risk Management and Treatment

Pharmacologic Therapies

For patients with major depressive disorder and suicidal ideation, the VA/DoD recommends ketamine infusion as adjunctive therapy for rapid improvement of suicidal ideation symptoms (within 24 hours).

For patients with unipolar depression or bipolar disorder, lithium is recommended to reduce the risk for suicide, as several studies associated lithium maintenance therapy with fewer suicidal behaviors and deaths.

In patients with schizophrenia or schizoaffective disorder who have a history of attempted suicide or suicidal ideation, clozapine is recommended to reduce suicidal behaviors. The VA/DoD mandates that frequent visits to healthcare providers and close monitoring of laboratory results are required for patients receiving clozapine therapy.

Nonpharmacologic Therapies

Cognitive-behavioral therapy (CBT) is recommended to reduce suicidal ideation and behavior as well as hopelessness in patients with a history of self-directed violence. Several studies suggested that CBT-based interventions focused on suicide prevention could reduce suicide attempts and suicidal ideation by 50% or more among an at-risk population.

Dialectical behavior therapy, which was originally developed to treat patients with borderline personality disorder and recent self-directed violence, is recommended by the VA/DoD to reduce suicidal ideation and repetition of self-directed violence following a suicide attempt.

The VA/DoD also supports the use of a crisis response plan for patients with suicidal ideation or a lifetime history of suicide attempts. A crisis response plan should involve a collaborative approach between the clinician and the patient and include a semistructured interview, a conversation about recent stressors, identification of self-management skills and social support, and a review of crisis resources.

Clinicians are recommended to offer problem-solving therapies to improve hopelessness in patients with moderate-to-severe traumatic brain injury who are at risk for suicide and to improve suicidal ideation and suicidal behaviors in patients with a history of self-directed violence.

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Other Interventions

After psychiatric hospitalization for suicidal ideation or suicide attempt, and in addition to usual care, the VA/DoD recommends sending periodic caring communications (such as postcards or letters) repeatedly for 12 to 24 months.

Although technology-based interventions for patients with suicidal ideation can increase access and continuity of care in rural populations or for persons who are frequently deployed, not enough evidence exists to recommend for or against technology-based behavioral health treatment methods as an adjunct to routine suicide prevention.

Recommendations for Other Management Methods

The VA/DoD suggests that implementation of lethal means safety — which reduces access to firearms, poisons, medications associated with overdose, and barriers to jumping from lethal heights — is an effective way to decrease suicide rates at the population level.

Although community-based interventions have been used as an approach to population suicide prevention for more than half a century, insufficient evidence prevents the VA/DoD from recommending for or against community-based intervention that targets patients at risk for suicide, interventions to reduce population-level suicide rates, gatekeeper training alone to reduce suicides, and buddy support programs to prevent suicidal behaviors.


Sall J, Brenner L, Bell AMM, Colston MJ. Assessment and management of patients at risk for suicide: synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines [published online August 27, 2019]. Ann Intern Med. doi: 10.736/M19-0687