Psychology of consulting and coaching

A Menu of Options: Resources for Preventing Veteran Suicide in Rural Communities

Nathaniel V. Mohatt Rocky Mountain Mental Illness Research, Education, and

Clinical Center, Denver, Colorado, and University of Colorado Anschutz Medical Campus

Melodi Billera Denver Veterans Affairs Medical Center, Denver, Colorado, and

Rocky Mountain Mental Illness Research, Education, and Clinical Center, Denver, Colorado

Nathaan Demers Grit Digital Health, Denver, Colorado

Lindsey L. Monteith and Nazanin H. Bahraini Rocky Mountain Mental Illness Research, Education, and

Clinical Center, Denver, Colorado, and University of Colorado Anschutz Medical Campus

Suicide rates are higher in rural communities than in their urban counterparts. Of particular concern are veterans residing in rural communities, who have a 20% higher risk of dying by suicide than veterans who live in urban areas. The objective of this manuscript is to assess the availability of evidence-based and promising practices to support a community-based suicide prevention effort for rural veterans. We compiled a compendium of evidence-based and promising practices—the “menu of options”—with resources across 4 levels: increasing access to crisis services, enhancing primary care suicide prevention, training community members, and raising public awareness. We compiled resources from multiple sources, then reviewed and rated each one to arrive at consensus on the final selections. The final menu includes 70 resources. However, only 20 are tailored for veterans, only one for rural communities, and none for rural veterans. More research is needed to identify effective strategies and develop rural-tailored resources for preventing suicide among this unique and often underserved population. The menu of options represents a first step toward developing an approach to rural veteran-suicide prevention that aligns with evidence-based practice, theory, and a public health model for suicide prevention.

Keywords: suicide prevention, rural, veterans, public health, community-based

Supplemental materials: http://dx.doi.org/10.1037/ser0000203.supp

Suicide is one of the top 10 causes of death among all age groups and is the tenth leading cause of death overall (United States DHHS & Centers for Disease Control & Prevention, 2015a). Despite being preventable, suicide rates have been increasing steadily since 1999 (Curtin, Warner, & Hedegaard, 2016). Moreover, the increase in suicides has been growing faster in rural communities, widening a well-documented rural– urban disparity (Fontanella et al., 2015; Hirsch, 2006; United

States DHHS & Centers for Disease Control & Prevention, 2015b). Suicide rates in rural areas have been consistently higher than they are in urban areas throughout the world: As rurality increases, so, too, do suicide rates (Hirsch, 2006). Evidence also indicates that veterans die by suicide at dispro- portionately higher rates than civilians (United States DHHS & Office of Suicide Prevention, 2016), and rurality may serve as a compounding factor that increases risk for this population.

Nathaniel V. Mohatt, United States Department of Veterans Affairs, Veterans Health Administration, Rocky Mountain Mental Illness Re- search, Education, and Clinical Center, Denver, Colorado, and Depart- ment of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus; Melodi Billera, PTSD Residential Rehabil- itation Treatment Program, Denver Veterans Affairs Medical Center, Denver, Colorado, and Rocky Mountain Mental Illness Research, Ed- ucation, and Clinical Center; Nathaan Demers, Grit Digital Health, Denver, Colorado; Lindsey L. Monteith, Rocky Mountain Mental Illness Research, Education, and Clinical Center, and Department of Psychiatry, University of Colorado Anschutz Medical Campus; Nazanin H. Bahraini, Rocky Mountain Mental Illness Research, Education, and Clinical Center, and Departments of Physical Medicine and Rehabilitation and Psychiatry, Univer- sity of Colorado Anschutz Medical Campus.

This work was supported by a grant from the United States Department of Veterans Affairs (VA), Office of Rural Health (N19-FY15Q1- S1-P01432). We would also like to acknowledge the contributions of the Western Interstate Commission for Higher Education (WICHE) as a critical partner in the research study and development of this article. In addition, Nathaniel V. Mohatt and Nathaan Demers both previously worked for WICHE during the course of this study. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Veterans Affairs or the U.S. Government.

Correspondence concerning this article should be addressed to Nathaniel V. Mohatt, Rocky Mountain Mental Illness Research, Education, and Clinical Center, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Mail Stop F493 AO1, Rm 2510, Aurora, CO 80045. E-mail: nathaniel.mohatt@va.gov

Psychological Services In the public domain 2018, Vol. 15, No. 3, 262–269 http://dx.doi.org/10.1037/ser0000203

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Veterans residing in rural areas experience a 20% higher risk of dying by suicide than veterans who live in urban areas (Mc- Carthy et al., 2012).

Several factors likely contribute to the increased risk for suicide among rural veterans. First, access to care is a major barrier for rural veterans. To receive care from the United States Veterans Health Administration (VHA), veterans living in rural areas typi- cally have to travel long distances, which can impede accessing care (Fortney, Booth, Blow, Bunn, & Loveland Cook, 1995; Mc- Carthy & Blow, 2004; Weeks, Wallace, West, Heady, & Haw- thorne, 2008). Consequently, rural veterans are less likely to take advantage of VHA care (Buzza et al., 2011; West & Weeks, 2006) and often have to forgo care or rely more heavily upon their communities for services (Rost, Smith, & Taylor, 1993). Unfor- tunately, rural communities often have fewer options for veterans’ access to mental health care because it is limited (Stewart, Jame- son, & Curtin, 2015), as is primary care (Weeks et al., 2008). Second, individuals residing in rural communities, including both civilians and veterans, may be at increased risk for suicide by virtue of specific cultural values that deter help-seeking and in- crease access to lethal means (Alston, 2012; Hirsch, 2006; Judd, Cooper, Fraser, & Davis, 2006; Mojtabai et al., 2011). The stigma associated with mental health disorders and seeking mental health care in rural communities is greater than that reported in more urban communities (Hirsch, 2006; Humensky et al., 2012; Moj- tabai et al., 2011). Likewise, there is strong evidence that rural residents are more likely to use firearms in lethal suicide attempts, which also may contribute to their higher risk of dying by suicide (Searles, Valley, Hedegaard, & Betz, 2014).

The 2012 National Strategy for Suicide Prevention encouraged multilevel community-based strategies (United States DHHS & the National Action Alliance for Suicide Prevention, 2012). Rather than targeting individuals, community-based prevention programs use a public health approach to reduce suicide risk (and improve health) within a population (Caine, 2013). To do so, community- based prevention programs employ multiple interventions to ad- dress a wide variety of risk and protective factors relevant to individuals and groups within the community. Community-based suicide-prevention programs have been demonstrated to signifi- cantly reduce suicide (Hegerl, Rummel-Kluge, Värnik, Arensman, & Koburger, 2013; Knox, Litts, Talcott, Feig, & Caine, 2003; Knox et al., 2010). In addition, community-based approaches have been successfully customized to embrace the culture and values of specific at-risk populations (Cwik et al., 2016; Knox et al., 2010). One such example is the Air Force Suicide Prevention Program (AFSPP; Knox et al., 2010), whose aims include reducing stigma, promoting help-seeking, educating the community, and shaping attitudes toward distress and suicide. The AFSPP has demonstrated significant reductions in suicide rates—33% over a 4-year period. Although community-based suicide-prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none has been designed or implemented for rural veterans.

To address the need for effective suicide-prevention programs for rural veterans, we partnered with a rural community in the western United States to develop and implement a community- based approach to preventing suicide among rural veterans. Be- cause rural communities may differ in their needs and readiness for implementing different suicide-prevention strategies, our approach

integrated different individual- and community-level strategies into a comprehensive program that can be customized to a comm- unity’s specific needs. Thus, the program offers flexibility within the context of an empirically supported public health model.

One of our goals is to align the implementation of a community- based suicide-prevention program with an established model of evidence-based practice (EBP). For providers in the field of med- icine, EPB often induces discussions about which interventions have the best empirical evidence supporting their effectiveness. This line of discussion lends itself to the use of an evidence-based intervention. However, EBP applies to much more than evaluating the merit of singular intervention strategies. Within the last decade, the development of the newest model of EBP, the transdisciplinary model of EPB places decision-making at its core (Satterfield et al., 2009). Deciding how to intervene is a combination of considering research evidence, client needs, values, preferences, and other available resources (e.g., provider training, skills, and partner- ships). All of these variables are considered within the context of the environment within which the practice will occur. Unique community contexts may influence the feasibility of implementing certain interventions and any necessary adaptations that should be made. This most recent model highlights strengths in practice, compensates for potential areas of weakness of any discipline that may use it, and emphasizes collaboration and shared decision making between providers and clients.

We seek to apply this model of EBP for implementing the public health approach to community-based suicide prevention. For a community-based suicide-prevention program, clients include communities as well as individuals. Following from the transdis- ciplinary model of EBP, efforts to prevent suicide among rural veterans need to address the barriers that veterans in rural com- munities face, while also customizing prevention efforts to the specific communities and cultures where rural veterans reside. Rapkin and Trickett (2005) identified the development of a “caf- eteria” of tools for use in collaborative health program implemen- tation as one approach to maximizing health outcomes in community-based research and prevention programs. Rather than provide the same suicide-prevention program across all commu- nities, we developed a “menu of options” consisting of evidence- supported practices and resources. The menu offers a variety of interventions and resources that communities can choose from to customize different levels of intervention to meet their unique needs. Thus, the menu may serve to support decision-making between suicide-prevention professionals and communities.

In this manuscript, we have described the development of the menu of options and evaluate the available resources included in the menu to inform research and practice for suicide prevention among rural veterans. Our guiding research question was how many resources are available that are tailored for rural, veteran, and rural veteran populations relative to urban civilian populations. We hypothesized that there would be fewer resources developed for rural populations relative to urban, and fewer resources devel- oped for veteran than civilian populations. Likewise, we hypoth- esized that there would be very limited resources available specif- ically for rural veteran populations. However, given our goal of developing a menu of options that communities could work with to select interventions and resources and tailor them to their commu- nities, we were primarily interested in identifying a large and diverse set of resources that fit within an evidence-based model for

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public health suicide prevention. Our objective in developing the menu was to examine the feasibility of creating a menu of options for the planning of a rural veteran suicide-prevention program, as well as to identify areas of need for future research and service development for rural and veteran suicide prevention.

Method

Description of the Multilevel Model

Our rural veteran suicide-prevention program uses a multilevel, public health approach to prevent suicide. The intervention levels are grounded in the research literature on the most effective public health approaches for suicide prevention (Van der Feltz-Cornelis et al., 2011). The initial development of the program was modeled after the European Alliance Against Depression (EAAD) program, which uses a four-level suicide-prevention approach: Increase ac- cess to crisis services, enhance suicide prevention in primary care, train community gatekeepers, and reduce stigma and raise aware- ness (Hegerl et al., 2008). Consistent with the EAAD, the pro- gram’s intervention levels work together to simultaneously address individual-level risk factors and community-level barriers that place rural veterans at risk for suicide. We organized the levels to correspond to the continuum of public health strategies from indicated to selective to universal prevention strategies (Knox, Conwell, & Caine, 2004), with level one corresponding to services for individuals at highest risk of suicide (indicated) to level four being a community-wide (universal) strategy.

Level 1: Crisis intervention. Level one directly targets rural veterans who are at increased risk for suicidal crises, in addition to local community agencies that are likely to provide medical care to rural veterans during a suicidal crisis or following a suicide at- tempt. To accomplish this goal, information is provided to rural veterans and community agencies regarding VHA and community resources for crisis and support services. The expected impact of this level of community intervention is to increase awareness and utilization of VHA- and community-crisis and -support services.

Level 2: Enhanced education and training in primary care. The second level of the program aims to prevent suicide among rural veterans by providing education on suicide and associated risk factors (e.g., depression) to primary care providers. This is accomplished by distributing resources and providing trainings to primary care providers in rural communities. The expected impact of this level of intervention is to increase primary care providers’ knowledge and practice regarding suicide risk assessment, mental health screening, and guideline-concordant care for rural veterans at risk for suicide.

Level 3: Train community gatekeepers. The third interven- tion level addresses suicide by training rural community members (i.e., lay citizens and professionals, such as clergy, first responders, teachers, and school personnel) in recognizing the warning signs of suicide and helping veterans in need access professional care. This is accomplished by providing gatekeeper training for community members likely to interact with veterans who are at risk for suicide, for example, the Question, Persuade, Refer (Qprinstitute.com, 2017), applied suicide-intervention skills training (LivingWorks, 2017), and (Mental Health First Aid, 2017). The anticipated impact of this level of intervention is to improve the rural community’s

ability to identify and refer veterans at risk for suicide, thereby, increasing access to care.

Level 4: Raise public awareness. The final level aims to prevent suicide by raising public awareness regarding mental health issues and by reducing stigma. This entails conducting a public relations campaign (e.g., through posters, advertisements, billboards, and public service announcements) within the commu- nity to reduce stigma about mental health and increase the accept- ability of seeking help. The anticipated impact of this level of intervention is to decrease stigmatizing attitudes regarding mental health among rural community members and to change negative attitudes regarding the acceptability of seeking mental health care.

Review and Selection of Resources

To develop the menu of options, we engaged in a systematic process of identifying and subsequently evaluating different prom- ising practices and innovative resources. This systematic process included searching, collecting resources, rating them, deciding on the inclusion or exclusion of resources, and refining the levels of intervention.

Online search. The first step in the review and selection of resources involved an online search designed to cast a wide net to identify available resources for implementing at each level of the model. We searched for key words in a variety of databases and Internet search engines, and then reviewed the results to identify interventions and suicide-prevention resources (e.g., apps, pocket cards, posters, websites, crisis lines). Key search terms included the general terms “suicide” or “suicide prevention” in combination with the focused terms including, but not limited to “rural,” “vet- eran,” “crisis intervention,” “crisis services,” “gatekeeper train- ing,” “training,” “behavioral health,” “substance use,” “primary care,” and “public awareness.” We searched initially through ac- ademic databases (PsycINFO, PubMed, Google Scholar) and suicide-prevention websites, i.e., the Suicide Prevention Resource Center (SPRC) and the United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-Based Programs and Practices (Nrepp.samhsa.gov, 2017). In addition, we con- ducted a general Internet search using Google and targeted search- ing through local and state resources relevant to our local com- munity partner.

The search process was iterative, similar to snowball sampling, meaning results from one search, website, or resource often led to another, which led to another. In this way, we did not strictly limit our search to the initial keywords or sources. Therefore, unlike a systematic review of the research literature, this step was a process of discovery in that we searched through the information available online to identify suicide-prevention resources until we reached a point of saturation (Fusch & Ness, 2015), that is, when we stopped finding new information or resources.

Identifying suicide-prevention resources. A second step in- volved narrowing the resources identified through the initial search to create a preliminary list of possible suicide-prevention resources to include in the menu of options. A resource was included in this initial list if it was related to suicide prevention on one of the four levels of intervention, that is, to be selected for further review, a resource had to apply to campaigns of suicide prevention and public awareness, gatekeeper training, primary care, or crisis ser-

264 MOHATT, BILLERA, DEMERS, MONTEITH, AND BAHRAINI

vices. For each resource, we collected name, website, phone num- ber, and accessibility (e.g., if the resource was free or available online); whether the resource was developed for rural populations or aimed at military or civilian populations; whether the VHA or non-VHA was targeting local or national users; if focused on prevention, postvention, or intervention; and whether there was empirical support available. In evaluating the resources for cultural fit for veterans, we grouped together all resources developed explicitly for veterans or tailored for military culture. Once the search reached the point of saturation (i.e., the search process was not identifying new resources), we began evaluating and rating each of the resources collected.

Final selection. The third step in developing the compendium involved rating the resources and arriving at consensus. An inter- disciplinary team of four mental health professionals conducted the ratings, including two clinical psychologists, one clinical social worker, and one community psychologist, all with expertise in suicide prevention. The team consisted of two women and two men, with a combined 34 years of professional experience, includ- ing 13 years of professional experience in mental health and suicide prevention with military and veteran populations and 15 years of experience in rural mental health and prevention services. Two were VHA employees specializing in the treatment and research of suicidality among veterans. The other two were plan- ners and researchers in rural mental health systems, and both had worked previously with military and veteran populations and in provision of clinical services in rural communities. One rater possessed additional experience in public health services in rural communities.

Each reviewer first rated the resources independently. Each resource was rated on a scale of 1 to 4 across the following domains: Scope, Rurality, Veteran Focus, and Supporting Evi- dence. Table 1 displays the domain definitions and rating scales. Generally, a score of 1 would indicate that the resource was not applicable for the rural veteran suicide-prevention program, whereas a score of 4 indicated maximum applicability.

The independent ratings were then combined and evaluated for inclusion or exclusion of the resource. The cutoff score for inclu- sion was defined as a rating of 9.5 or higher out of a possible score

of 16, which corresponds to an average domain score of 2.375, as this number indicates that the resource was more aligned than not (i.e., average domain score � 2) with the sought criteria. After combining the ratings and reducing the list of possible resources based on the cutoff score, raters met to arrive at consensus on the final list. To arrive at consensus, we first reviewed the resources included versus excluded based on their scores. This brief review of the results of our derived cutoff point provided an opportunity for any rater to contest whether a resource should be included or excluded. For any resource that any one rater felt was unfairly included or excluded, we discussed that specific resource in more detail until all members of the group agreed upon the resource’s inclusion or exclusion.

Results

We identified over 300 possible practices or resources through the initial online search process described above. After the initial online search phase, we narrowed the results to138 unique re- sources that met the criteria for focused suicide prevention and fitting within one of the four levels of our model. The final selection process, which involved rating resources and arriving at consensus, yielded 70 resources across all four levels for inclusion in the menu of options. Table 2 depicts the total number of resources, the number of resources tailored for veteran or military populations, and the number of resources tailored for rural popu- lations, broken down by level of intervention. Additionally, an appendix is available as supplementary material to the article, which provides the complete menu of options with resource name, type, whether the resource is for veteran or military populations, whether it is for rural communities, and whether there is support- ing evidence.

Although we were able to find numerous resources to imple- ment the four evidence-based levels for community-based suicide prevention, most of the resources in the menu of options are not tailored to either veterans or rural populations. Less than one third of the resources is tailored to the veteran population. As shown in Table 2, of 21 total veteran-tailored resources, eight are for crisis services, two for primary care suicide prevention, seven for gate-

Table 1 Resource Rating Domains and Scale

Domain Definition Rating scale

Scope Extent to which the resource aligns with the scope and goals of the rural veteran-suicide prevention program

1 � No applicability 2 � Requires significant modifications 3 � Fits with slight modifications 4 � In alignment

Rurality Extent to which the resource can be applied to rural populations

1 � Does not apply to rural populations 2 � Requires significant modifications 3 � Fits rural with slight modifications 4 � Designed for rural populations

Veteran Focus Extent to which the resource can be applied to veteran populations

1 � Inappropriate for veteran populations 2 � Requires significant modifications 3 � Applies to veterans with minor modifications 4 � Designed for veteran populations

Published research support Supporting empirical evidence available 1 � No available supporting documentation 2 � Minimal qualitative data only 3 � Preliminary empirical data 4 � Empirically validated

265MENU OF OPTIONS

keeper training, and four for public awareness. Regarding rural resources, we identified only one resource tailored for rural pop- ulations—the Suicide Prevention Toolkit for Rural Primary Care Practices (WICHE & SPRC, 2009). Finally, we found no re- sources developed to simultaneously address the needs of both rural and veteran populations, specific to the four target- intervention levels (i.e., crisis services, primary care, gatekeeper training, and public awareness).

The menu of options also includes resources ranging from well-researched interventions to recently developed innovative approaches. Table 3 shows the number of resources included on the menu of options that are identified by the SPRC as best practices, included as part of the Suicide Prevention Research Center Library, and resources that have published support (pub- lished research support). Resources identified by the Best Prac- tices Registry (FAQs About the Best Practices Registry; BPR; SPRC, 2017) include resources across three levels: evidence-based programs that have undergone evaluation and demonstrated pos- itive outcomes; expert/consensus statements that summarize the current knowledge in the suicide prevention field and provide best-practice recommendations to guide program and policy de- velopment, and adherence to standards, which are resources whose content has been reviewed for the following criteria: accu- racy, likelihood of meeting the stated objectives, and adherence to program design standards (inclusion in this section means only that the program content meets the stated criteria). The Suicide Pre- vention Resource Library (SPRC Resources and Programs) is a collection of resource materials regarding suicide and suicide prevention, including SPRC resources, as well as materials devel- oped by public and private organizations and professionals. The collection is managed and regularly updated by experts from the SPRC. Resources included in the Published Research Support category have at least one published study reporting on the re- source’s efficacy or effectiveness. Of the resources in the menu of options, 81.1% were in the SPRC Library or the Best Practices Registry or had Published Research Support. As shown in Table 3,

20 resources were identified in the Best Practices Registry, 12 were included in the SPRC Library, and 24 had Published Re- search Support. The remaining 13 without current research support were new and innovative resources that had yet to be formally studied or were resources that may never be studied, but comprise elements of research-based suicide prevention (e.g., a brochure used as part of a public awareness campaign).

Discussion

The objective for compiling the menu of options was to reduce the amount of information that communities would have to sift through for implementing a community-based suicide- prevention program for rural veterans. The abundance of results from the initial search reinforced our conviction that a curated menu of options for community-based suicide prevention could, and should, be developed and maintained. By providing an up-to-date and professionally vetted menu of interventions and resources, communities will be able to use the menu to plan suicide-prevention initiatives without undertaking an indepen- dent search of the available options. The menu of options provides a compendium of suicide-prevention resources orga- nized by level of community intervention. The levels of inter- vention included in the menu are from the EAAD, a public health model for suicide prevention that has demonstrated suc- cessful reductions in suicide rates at the population level. Therefore, the menu of options provides not only a profession- ally curated list of quality resources and practices for rural veteran-suicide prevention, but is also organized to support the implementation of a comprehensive evidence-based model.

The 70 resources in total (i.e., the final count), divided relatively evenly across the four levels, provides ample evi- dence of the feasibility of developing a menu of options to assist with planning a community-based suicide-prevention pro- gram. The menu differs from other existing public registries, such as the SPRC Library, by narrowing the available options to best practices within a specific evidence-based public health model and for a specific population of interest and intervention strategy. The 21 veteran or military tailored resources provide a promising starting point for veteran-focused suicide- prevention efforts. With increasing national awareness of the need for suicide prevention among veterans, more resources for this population are being developed on a regular basis, both from the VHA and from veteran advocates. However, the lack of resources for rural communities highlights how little work has been done to develop interventions and resources targeting this disparity. Also, although many of the resources in the menu of options may translate to rural communities, the effectiveness

Table 2 Number of Total, Veteran, and Rural Resources for Each Level of the Menu of Options

Intervention level Total Veteran Rural

1. Crisis services 15 8 0 2. Primary care 14 2 1 3. Gatekeeper training 17 7 0 4. Public awareness 24 4 0 Total 70 21 1

Table 3 Research Support for the Menu of Options Resources

Variables Level 1 Level 2 Level 3 Level 4 All levels

Best practices 0/15 6/14 11/17 3/24 20 SPRC Library 0/15 3/14 3/17 6/24 12 Published research support 13/15 4/14 1/17 6/24 24 Total with research support 13/15 (86.7%) 13/14 (92.9%) 15/17 (88.2%) 15/24 (62.5%) 56/69 (81.1%)

Note. SPRC � Suicide Prevention Resource Center (http://www.sprc.org/resources-programs).

266 MOHATT, BILLERA, DEMERS, MONTEITH, AND BAHRAINI

of these resources has not been established for rural popula- tions. The lack of rural and rural veteran resources places emphasis on the significance of the current project.

Given that suicide rates in rural communities are increasing, relative to urban areas (Curtin et al., 2016), our findings support a clear need for increased research on effective strategies spe- cific to rural contexts. For example, there is robust evidence of the effectiveness of a variety of gatekeeper-training strategies, but to what extent do rural contexts, such as health-care work- force shortages and long distances to emergency services, in- fluence the effectiveness of these programs? Also, there may be cultural messages that could be included in trainings for rural communities to make them more culturally responsive, hence, more effective for preventing suicide among rural veterans. Emphasizing how to address cultural values of self-reliance and rural firearm ownership may be critical to include in rural suicide-prevention trainings. Similarly, to what extent would crisis-line effectiveness increase if there were a concerted effort to raise awareness among crisis-line workers of rural issues and needs? These are just a few potential research needs regarding improving intervention strategies for rural suicide prevention.

These questions also hint at a larger gap in the research on rural suicide that limits the ability to identify and develop effective strategies for rural veterans, that is, there has been little research identifying the primary drivers of the suicide disparity between rural and urban communities more generally, let alone specifically between rural and urban veterans. A 2006 review of the evidence on rural suicide identified greater de- grees of stigma toward suicide, mental illness, and help- seeking, as well as increased geographic and social isolation and economic and social fragmentation as risk factors for suicide associated with rurality (Hirsch, 2006). However, the authors of this study concluded that more research was needed to understand the ways in which rurality influences suicide risk. To improve suicide-prevention for rural veterans, we recom- mend further investigation into unique risk and protective fac- tors that may be present in rural settings. Through identification of risk and protective factors for suicide, such as barriers to treatment and cultural values, existing interventions and re- sources can be subsequently tailored to better address rural contexts, or new rural-specific strategies can be developed.

We developed the current menu of options through a system- atic process, in which we sought to compile the best available resources for suicide prevention among rural veterans. We first surveyed the field by searching academic databases, key web- sites providing suicide-prevention resources, and the Internet more broadly to try to identify best practices, with specific attention to finding rural and veteran-tailored resources. Then we proceeded through a series of steps to identify the best interventions and resources, resulting in a compendium of re- sources to support implementation of suicide prevention across four evidence-based levels of community intervention. How- ever, we did not conduct a systematic review of the research. This choice was purposeful because we were searching for possible resources to use, regardless of whether they had been or could be studied via randomized controlled research. For example, there may not be randomized controlled trials of a poster, but there is substantial evidence to support the effec- tiveness of public awareness campaigns (Torok, Calear, Shand,

& Christensen, 2016). Nonetheless, it is important to recognize that most of the resources in the menu of options are not themselves evidence-based practices, rather, they are individual components of evidence-based suicide-prevention programs.

There are some important limitations to our review of the available resources for rural veteran-suicide prevention. First, as noted previously, the majority of suicide-prevention programs center on individual clinical and crisis services. Nonclinical inter- ventions generally have a more limited evidence base. Recent reviews of suicide prevention and intervention highlight the sub- stantial need to conduct more empirical research to better develop the evidence base for community interventions, such as gate- keeper training and antistigma campaigns (Mann et al., 2005; Van der Feltz-Cornelis et al., 2011). Second, the current state of suicide-prevention programs and evidence-based practices is constantly changing. Every year, new resources are developed and new evidence emerges for best practices. Therefore, the menu of options will be most useful as a living compendium that is reviewed regularly for quality control, during which new resources may be added, information regarding current re- sources will be verified as correct, and evidentiary support for included resources will be updated. Third, our goal is to use the menu of options as a tool for implementing community-based rural veteran suicide prevention. However we have yet to eval- uate the menu’s utility as an implementation tool. We are currently conducting a pilot implementation of the rural veteran-suicide-prevention program, which will provide an im- portant opportunity to evaluate the acceptability and utility of the menu for rural communities in planning and implementing community-based prevention.

Conclusion

The menu of options provides an important resource and increases our knowledge of the availability of best-practice resources for rural community-based suicide prevention for veterans and their families. The final menu includes multiple, high-quality resources at each of the EAAD’s four levels of community-based intervention. In compiling resources for the menu, we confirmed that there is a stark lack of resources specifically targeting rural contexts, cultures, and risk factors, all of which influence the elevated suicide risk of rural veterans. Given the high rates of suicide among veterans and in rural communities, more research is needed to identify effective strategies and develop rural-tailored resources for rural veter- ans. The menu of options represents a first step toward devel- oping and evaluating an approach to rural veteran-suicide pre- vention that aligns with evidence-based practice and theory and a public health model for suicide prevention. Having the ability to offer communities a menu of options that contains many quality resources enhances communities’ capacity to implement effective, community-based suicide prevention tailored to local needs and cultures. Although more research on its utility as a tool to improve implementation of community-based interven- tions for and prevention of veteran suicide in rural communities is needed, the menu of options provides a resource for active community participation in suicide-prevention planning to sup- port local determination of the specific intervention strategies.

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Received May 26, 2017 Revision received August 16, 2017

Accepted August 25, 2017 �

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