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Providers should screen veterans for suicide risk, and use psychosocial and pharmacologic interventions when appropriate, according to an updated guideline from the U.S. Department of Veterans Affairs and the Department of Defense.

The guideline includes three screening algorithms that can guide clinicians towards the use of cognitive behavioral therapy (CBT) or agents like ketamine and lithium for certain patients who screen positive for suicide risk, according to James Sall, PhD, of the Veterans Health Administration (VA), and colleagues in the .

They add 22 entirely evidence-based recommendations to the , Sall told MedPage Today in an email.

Compared with peers of the same age and sex, veterans have a ; each day, 20 veterans die by suicide, according to Sall and colleagues.

The guideline is based on a VA-commissioned by Kristen D'Anci, PhD, of the ECRI Institute in Plymouth Meeting, Pennsylvania. D'Anci's group qualitatively looked at eight existing systematic reviews and 15 randomized control trials.

They found "moderate" evidence that CBT reduced suicide attempts and suicidal ideation versus treatment as usual, as well as "moderate" evidence that dialectical behavior therapy reduced suicide ideation versus client-oriented therapy.

Short-term intravenous use of ketamine reduced suicide ideation among patients with major depressive disorder, bipolar disorder, or posttraumatic stress disorder, according to the review. Lithium also reduced suicides among patients with unipolar and bipolar mood disorders, although no benefit was found when lithium was compared with other active treatments for mood disorders, the authors noted.

Eric D. Caine, MD, of the University of Rochester Medical Center in New York, recommended approaching the evidence included in this review -- which showed "at most, modest benefit for both psychosocial and psychopharmacologic interventions" -- with caution.

First, the majority of trials supporting the use of psychotherapy involved more women than men, while roughly . Also, studies of this nature often have high attribution rates and may require additional psychological support that contributes to positive results, Caine wrote in an .

The evidence for the use of psychopharmacologic agents was "similarly murky," Caine noted. Many were industry-sponsored or based on databases maintained by the VA.

"If one is mindful of these cautions, the guidelines are as good as one will now find in the United States," Caine wrote.

Sall and colleagues recommended restricting access to lethal means, including firearms, but did not include recommendations on screening military members and veterans for gun ownership.

Michael Hogan, PhD, of Case Western Reserve School of Medicine in Cleveland noted in an that implementing firearm safety measures may be particularly helpful in reducing suicide among veterans, since approximately half of suicides within this population are conducted with the use of guns.

Sall's group said limited evidence was available for determining how levels of suicide risk relate to treatment, as well as the efficacy of community-based interventions. This was surprising, Sall said, since "that is where we often dedicate most of our resources."

Hogan explained this absence of evidence "may be the result of inadequate research or a limited definition of evidence."

"Suicide is uncommon enough that very large studies are necessary to robustly define the effectiveness of interventions," he wrote. "Because research related to suicide prevention is woefully underfunded, such studies are lacking."

Also missing from this systematic review is a comparison of how suicide prevention measures in the U.S. differ from countries like Denmark and Finland -- both roughly the size of the U.S. -- in which suicide rates have markedly decreased in the past few decades, Caine noted.

Namely, it seems suicide prevention in those countries is based on the idea that "prevention begins long before someone becomes suicidal, which is akin to dealing with asymptomatic hypertension," he explained.

"Approaches in the United States depend largely on engaging symptomatic persons when they seek care, as we see in these guidelines," he wrote. "Experiences in other countries invite us to look beyond narrowly defined forms of evidence to ask questions and conduct research that we in the United States have avoided thus far."

Hogan called for a greater emphasis to be placed on community-interventions for suicide, noting that more than two-thirds of the veterans who die by suicide are not not enrolled in the VA health system. In these guidelines, the authors cited "insufficient" evidence regarding community-based suicide prevention strategies.

Among veterans who are enrolled, suicide rates have decreased, Hogan noted, possibly due to the 2013 guidelines that required suicide prevention specialists to be employed at VA centers and precipitated the development of the .

But much of the work in reducing veteran suicides "depends largely on actions to improve suicide care outside the VA," according to Hogan.

Increased suicides among veterans is part of the national suicide crisis, he wrote, and "lowering adult suicide rates overall would probably reduce suicide rates among veterans, but the VA cannot do it alone."

If you or someone you know is considering suicide, call the National Suicide Prevention Hotline at 1-800-273-8255.