QUERI – Quality Enhancement Research Initiative

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Randomized Evaluation of a Caring Letters Suicide Prevention Campaign

Seattle, WA


The Randomized Evaluation of a Caring Letters Suicide Prevention Campaign aims to test the effects of a Caring Letters Campaign on Veteran Crisis Line (VCL) callers. A growing body of evidence suggests that post-discharge follow-up contacts with high-risk patients may be an effective suicide prevention strategy. Caring contact interventions include:

  • Postcards and/or letters containing brief expressions of caring;
  • Telephone follow-up contacts with patients after discharge; and
  • Telephone calls combined with in-person contact.

 Figure 1. Caring Contacts and Interpersonal Theory of Suicide

A recent VA study also suggests that that most Veterans at high risk of suicide would perceive Caring Contacts as helpful and caring. Veteran psychiatric inpatients (n=154) completed a patient preferences survey to obtain feedback on Caring Contact methods. Study results revealed that 85% of Veterans Agreed or Strongly Agreed that they would like to receive Caring Contacts from at least one of the correspondent options with an inpatient or outpatient mental health counselor, or a primary care physician most preferred. Letters or postcards sent through postal mail were preferred over e-mail or text messages. Veterans most commonly thought Caring Contacts should be sent monthly for a period of one year (Reger et al., 2018).


Specific aims for Suicide Prevention QUERI include to:

  • Evaluate the effects of Caring Letters on clinical outcomes and VA clinical utilization rates;
  • Examine the facilitators and barriers to implement the Caring Letters intervention to determine how to improve implementation and sustainability across the VA healthcare system; and
  • Conduct budget impact analyses of implementing the Caring Letters program in VA – from the perspective of the healthcare system.

Potential Impacts:

The largest test of the Caring Letters intervention thus far, Suicide Prevention QUERI investigators will evaluate an adapted version of the traditional Caring Letters model among Veteran Crisis Line callers. The Caring Letters intervention is well-suited for a large-scale impact among individuals at high risk of suicide, and this study is expected to inform potential improvements for implementation.

Principal Investigators: Mark Reger, PhD, also is part of the VA Puget Sound Health Care System; contact at Mark.Reger@va.gov .

Operational Partners: Veteran Crisis Line, Seattle, WA.