pmc JAMA Netw Open JAMA Netw Open 3211 jamasd 101729235 JAMA Network Open 2574-3805 pmc-is-collection-domain yes pmc-collection-title JAMA Network PMC12238888 PMC12238888.1 12238888 12238888 40627357 10.1001/jamanetworkopen.2025.19513 zld250109 1 Research Research Letter Online Only Psychiatry The REACH VET Program and Mortality Outcomes Among Veterans at High Risk of Suicide The REACH VET Program and Mortality Outcomes in Veterans at High Risk of Suicide The REACH VET Program and Mortality Outcomes in Veterans at High Risk of Suicide Dent Kallisse R. MPH MS 1 2 3 Cooper Samantha MPH 1 McCarthy John F. PhD MPH 1 2 4 1 Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health, Department of Veterans Affairs, Ann Arbor, Michigan 2 Office of Suicide Prevention, Department of Veterans Affairs, Ann Arbor, Michigan 3 Department of Psychology, University of Michigan, Ann Arbor, Michigan 4 Department of Psychiatry, University of Michigan, Ann Arbor, Michigan Article Information Accepted for Publication: May 2, 2025. Published: July 8, 2025. doi: 10.1001/jamanetworkopen.2025.19513 Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2025 Dent KR et al. JAMA Network Open . Corresponding Author: Kallisse R. Dent, MPH, MS, Department of Psychology, University of Michigan, 530 Church St, Ann Arbor, MI 48109 ( dentkr@umich.edu ). Author Contributions: Ms Dent had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: All authors. Acquisition, analysis, or interpretation of data: Dent, McCarthy. Drafting of the manuscript: Dent. Critical review of the manuscript for important intellectual content: All authors. Statistical analysis: Dent. Supervision: McCarthy. Conflict of Interest Disclosures: None reported. Funding/Support: This study was conducted as part of ongoing operations work in the Veterans Affairs (VA) Office of Suicide Prevention (OSP) and was funded by OSP. Role of the Funder/Sponsor: The VA OSP had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation of the manuscript. The VA OSP reviewed and approved the manuscript for submission and the decision to submit the manuscript for publication. Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA. Data Sharing Statement: See Supplement 2 . 8 7 2025 7 2025 8 7 492541 e2519513 10 2 2025 2 5 2025 08 07 2025 10 07 2025 10 07 2025 Copyright 2025 Dent KR et al. JAMA Network Open . https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License. jamanetwopen-e2519513.pdf This cohort study investigates the association of the Veterans Health Administration Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET) program with suicide and mortality outcomes among veterans at high risk for suicide. pmc-status-qastatus 0 pmc-status-live yes pmc-status-embargo no pmc-status-released yes pmc-prop-open-access yes pmc-prop-olf no pmc-prop-manuscript no pmc-prop-legally-suppressed no pmc-prop-has-pdf no pmc-prop-has-supplement yes pmc-prop-pdf-only no pmc-prop-suppress-copyright no pmc-prop-is-real-version no pmc-prop-is-scanned-article no pmc-prop-preprint no pmc-prop-in-epmc yes pmc-license-ref CC BY Introduction To support veterans at high risk for suicide, 1 the Veterans Health Administration (VHA) developed a suicide risk prediction algorithm 2 and implemented the Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET) program. 3 It identifies VHA patients at high risk for suicide (top 0.1% risk tier), providing outreach and care coordination. An effectiveness evaluation of the REACH VET program documented reductions in nonfatal suicide attempts but did not identify associations with suicide mortality. 4 Those mortality analyses were limited to a 6-month period for a subset of the study cohort. This study evaluates the association of REACH VET with mortality outcomes through 24 months for an expanded cohort. Methods Analyses were conducted as a part of Veterans Affairs Office of Suicide Prevention operations, and institutional review board review was not required. We followed the STROBE reporting guideline for cohort studies. A differences-in-differences design was used to evaluate the association of REACH VET with suicide, external-cause mortality, and all-cause mortality. The intervention group included patients who were identified in the top 0.1% risk tier during the REACH VET implementation period (March 2017 to June 2021). A subthreshold high–risk tier group (top 0.3%-0.1% risk tier) was identified as a control group. Comparable groups were also identified during a preintervention period (March 2014 to December 2015). Mortality was assessed using national death certificate data through 2021 per the Veterans Affairs/Department of Defense Mortality Data Repository. Cox proportional hazards regression was used to estimate the association of the REACH VET program with mortality outcomes across 6-, 12-, and 24-month follow-up periods adjusting for age and sex. The eMethods in Supplement 1 provides detailed information on study methods. Significance was assessed using 2-tailed χ 2 tests, with α = .05. Results The analytic cohort consisted of 266 246 observations (92.3% male; 0.6% American Indian or Alaskan Native, 0.9% Asian, Native Hawaiian, or Other Pacific Islander, 14.2% Black, 81.4% White, 1.6% multiple racial groups, and 1.3% unknown or missing; 91.0% non-Hispanic; mean [SD] age, 51.2 [15.0] years). Accounting for potential period and cohort differences, inclusion in the REACH VET program was not associated with suicide mortality (6-month hazards ratio [HR], 1.18 [95% CI, 0.83-1.69]; 12-month HR, 1.25 [95% CI, 0.94-1.67]; 24-month HR: 0.92 [95% CI, 0.68-1.24]) ( Table ). Similarly, inclusion in REACH VET was not associated with risk for external-cause mortality (6-month HR, 0.99 [95% CI, 0.80-1.23]; 12-month HR, 1.07 [95% CI, 0.91-1.27]; 24-month HR, 1.06 [95% CI, 0.90-1.25]) or all-cause mortality (6-month HR, 1.03 [95% CI, 0.93-1.15]; 12-month HR, 1.04 [95% CI, 0.95-1.13]; 24-month HR, 1.03 [95% CI, 0.95-1.12]). Table. Association of the REACH VET Program With Mortality Outcomes Outcome Observations, No. Mortality, HR (95% CI) Total With outcome Pre–REACH VET Era a Post–REACH VET Era a DiD b Suicide 6 mo 266 246 566 1.40 (1.04-1.87) 1.65 (1.34-2.02) 1.18 (0.83-1.69) 12 mo 247 481 841 1.34 (1.06-1.69) 1.68 (1.42-2.00) 1.25 (0.94-1.67) 24 mo 178 048 904 1.58 (1.22-2.05) 1.46 (1.25-1.70) 0.92 (0.68-1.24) External-cause mortality 6 mo 266 246 1603 1.34 (1.11-1.60) 1.33 (1.18-1.49) 0.99 (0.80-1.23) 12 mo 247 481 2533 1.26 (1.10-1.45) 1.35 (1.23-1.49) 1.07 (0.91-1.27) 24 mo 178 048 3130 1.31 (1.14-1.51) 1.39 (1.28-1.50) 1.06 (0.90-1.25) All-cause mortality 6 mo 266 246 6976 0.80 (0.73-0.87) 0.82 (0.78-0.87) 1.03 (0.93-1.15) 12 mo 247 481 11 081 0.85 (0.79-0.91) 0.88 (0.84-0.92) 1.04 (0.95-1.13) 24 mo 178 048 13 686 0.91 (0.84-0.97) 0.93 (0.90-0.97) 1.03 (0.95-1.12) Abbreviations: DiD, difference in difference; HR, hazard ratio; REACH VET, Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment. a The association with mortality, adjusted for age and sex, is given for the top 0.1% risk tier vs the top 0.3% to 0.1% risk tier within the period prior to (pre–REACH VET era) or during (post–REACH VET era) REACH VET implementation. b The DiD association of the REACH VET program with mortality is given, adjusted for age and sex, with the HR equivalent to the ratio of the post–REACH VET era HR to the pre–REACH VET era HR. Discussion Consistent with previous reports, 4 this cohort study did not observe associations of REACH VET program inclusion with subsequent mortality outcomes. Findings highlight the complexities of suicide prevention. Although the REACH VET program has been associated with improvements in suicide-related risk factors, including suicide attempts, 4 this study replicated prior observations that program inclusion was not associated with mortality outcomes. Differential associations of the REACH VET program with nonfatal and fatal suicide attempts may be influenced by differences in characteristics of patients who attempt suicide vs those who die from suicide. Compared with patients with nonfatal suicide attempts, individuals who die by suicide tend to use more lethal methods and be older, more often male, and have more medical morbidity. 5 Considered alongside our findings, this suggests that the REACH VET program may be less effective for specific subpopulations of VHA patients at high risk, such as males or those using more lethal methods. Additional research is needed to evaluate these hypotheses. A limitation of this study was its low power to detect small associations for rare outcomes; power analyses suggest we would need approximately 1.4 million patients to observe a 10% difference in suicide risk across a 12-month follow-up. Furthermore, analyses may not have fully accounted for underlying group differences in mortality risks across time. Although REACH VET care coordination and outreach are important for improving mental health outcomes and preventing suicide attempts, additional approaches are needed to enhance suicide prevention for patients at high risk. References 1 Department of Veteran Affairs Office of Suicide Prevention . 2024 National veteran suicide prevention annual report part 2 or 2: report findings . Accessed December 27, 2024. https://www.mentalhealth.va.gov/docs/data-sheets/2024/2024-Annual-Report-Part-2-of-2_508.pdf 2 Kessler RC , Hwang I , Hoffmire CA , . Developing a practical suicide risk prediction model for targeting high-risk patients in the Veterans health Administration . Int J Methods Psychiatr Res . 2017 ; 26 ( 3 ): e1575 . doi: 10.1002/mpr.1575 28675617 PMC5614864 3 Department of Veterans Affairs . VA REACH VET initiative helps save veterans lives: program signals when help is needed for at-risk veterans. VA News. Accessed December 10, 2024. https://news.va.gov/press-room/va-reach-vet-initiative-helps-save-veterans-lives-program-signals-when-more-help-is-needed-for-at-risk-veterans/ 4 McCarthy JF , Cooper SA , Dent KR , . Evaluation of the recovery engagement and coordination for health-veterans enhanced treatment suicide risk modeling clinical program in the Veterans Health Administration . JAMA Netw Open . 2021 ; 4 ( 10 ): e2129900 . doi: 10.1001/jamanetworkopen.2021.29900 34661661 PMC8524305 5 Joo SH , Wang SM , Kim TW , . Factors associated with suicide completion: a comparison between suicide attempters and completers . Asia Pac Psychiatry . 2016 ; 8 ( 1 ): 80 - 86 . doi: 10.1111/appy.12216 26477349 Supplement 1. eMethods. Methodological Details for the Assessment of the REACH VET Program and Mortality Outcomes eReferences. Supplement 2. Data Sharing Statement