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Quality Enhancement Research Initiative

QUERI E-news
September 2020

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Evaluation: Caring Letters Suicide Prevention Campaign

Takeaway: The Caring Letters Suicide Prevention Campaign QUERI has partnered with VA’s Suicide Prevention Program and Office of Mental Health and Suicide Prevention to conduct the first-ever test of Crisis Callers – and will be the largest evaluation of a Caring Letters intervention ever conducted.

Mark Reger, PhD

Mark Reger, PhD

Led by Mark Reger, PhD, the Randomized Evaluation of a Caring Letters Suicide Prevention Campaign works to test the effects of a Caring Letters Campaign on Veteran Crisis Line (VCL) callers. The suicide rate among these callers is much higher than among other Veterans, and many of these callers may not be in mental health treatment. Thus, outreach is critical.

This QUERI Partnered Evaluation project will reach out to all VCL callers connected to VA over the course of one year with letters expressing care and support, as well as highlighting available VA resources for Veterans with mental health issues. The use of Caring Letters for suicide prevention is an evidence-based intervention that has been tested since the 1970s and is currently one of only two suicide prevention strategies that have reduced suicide rates in a randomized controlled trial. Further, a recent study that examined high-risk inpatient preferences for the Caring Contacts intervention showed that most Veterans at high risk for suicide would perceive Caring Contacts as helpful and caring, while 84% believed it would help individuals contemplating suicide. For example, following are a few quotes from Veterans who participated in this study.1

“[It] can’t hurt, maybe a message might help someone who is suicidal. Someone might be lonely and a simple letter might cheer them up and get help. I think these letters are a great idea.” Veteran participant.

“[When] feeling suicidal and isolating, it provides evidence someone still cares. I have been there.” Veteran participant.

 “If someone had reached out sooner, I might not be here [on the psychiatric inpatient unit].” Veteran participant.

“Just a reminder that there is someplace you can go. . .” Veteran participant.

QUERI investigators will tailor the use of Caring Letters to accommodate the unique situation of crisis line callers. The evaluation will examine two letter signatory models with 1) letters sent on behalf of a VA provider that the recipient does not yet know, and 2) a Peer Veteran model. While the latter presents a relatively new approach, the significance of peer support for Veterans is well documented. VCL callers will be identified weekly and randomized to one of the two intervention groups (two signatory types). Clinical outcomes and VA utilization rates among the contact groups will be compared with each other – and with rates from a comparable historical cohort of Veteran VCL callers

Anticipated Findings and Expected Impacts

The Caring Letters Suicide Prevention Campaign QUERI Partnered Evaluation is expected to provide vital data to leadership regarding the impacts of this campaign. Investigators will:

  • Assess whether the intervention affects health outcomes;
  • Answer important operational questions, such as the effects of Caring Letters on a new patient population;
  • Identify barriers and facilitators to program implementation and sustainability;
  • Emphasize Veteran engagement and input in the project design and evaluation; and
  • Assess the budget impact of implementing the Campaign across the VA healthcare system.

Results of this evaluation will help identify an effective and sustainable evidence-based practice to help prevent suicide on a public health scale.

QUERI National Partnered Evaluations (NPEs) involve primary funding from an operations partner in order to conduct specific evaluations of initiatives with potential high impact on VA national policy.

For more information, please contact Mark Reger, PhD at .


  1. Reger M, Gebhardt H, Lee J, et al. Veteran preferences for the Caring Contacts Suicide Prevention Intervention. Suicide and Life-Threatening Behavior. October 2019;49(5).

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