A program of nine “caring letters” mailed over a year to veterans who had contacted the Veterans Crisis Line was not associated with lower suicide mortality in the following 12 months, according to a prespecified secondary analysis of a large randomized trial published October 14, 2026, in JAMA Psychiatry. It also made no difference whether the letters were signed by a clinician or by a fellow veteran.
The peer-reviewed brief report, led by Mark A. Reger of the VA Puget Sound Health Care System and the University of Washington with colleagues at VA Boston, Boston University and the Veterans Crisis Line, analyzed 227,502 Veterans Health Administration patients aged 18 or older who contacted the crisis line. Their mean age was 53.6 years and 84.4% were men. Veterans who contacted the line between June 11, 2020, and June 10, 2021, were randomly assigned to receive letters signed by a VA clinician or by a peer veteran; 87,926 received the letters. A historical comparison group of 139,576 veterans who contacted the line between June 2018 and June 2021 did not receive the intervention.
There were 625 suicides overall, or 0.27% of the cohort, in the 12 months after the index contact. The rate was 0.29% among those who received caring letters and 0.27% among historical controls, a difference that was not statistically significant (P = .31). Within the letters group, 0.21% of those who received peer-signed letters and 0.22% of those who received clinician-signed letters died by suicide (P = .95). The authors conclude the intervention “may not reduce suicide mortality” among high-risk veterans who contact the line.
The comparison between letter recipients and non-recipients was observational, because only the signatory was randomized; the trial is registered as ISRCTN27551361. Funding details are not given on the journal’s summary page, but the parent trial was funded by a VA Quality Enhancement Research Initiative and the Veterans Crisis Line, according to a 2024 UW Medicine release.
Why it matters
Caring letters are among the oldest low-cost suicide prevention interventions, developed by the psychiatrist Jerome Motto: brief, simple messages, often postcards, that remind people at high risk that someone cares and that help is available. The parent trial, published in JAMA Network Open in April 2024, randomized 102,709 veterans and found no association between the letters and suicide attempts, but recipients were more likely to use VA care, including outpatient mental health care (hazard ratio 1.19; 95% CI, 1.17–1.22) and inpatient mental health care (hazard ratio 1.14; 95% CI, 1.07–1.21). The new analysis extends the null result from attempts to deaths.
The question matters because of the scale of the problem. Veteran suicide rates are 72% higher than those of nonveteran U.S. adults, and more than 6,300 former service members died by suicide in 2021, the most recent year cited in the UW release. The authors suggest future research look at the increased health care use seen in the parent trial, which may be the route through which such contacts could help, rather than a direct effect on deaths. “We really want to get the word out that asking for help is actually a sign of strength,” Reger, a professor of psychiatry at the University of Washington School of Medicine, said in the 2024 release.
The caveats
Suicide is a rare outcome even in a high-risk population, and a null result at 12 months does not rule out smaller effects or effects over longer periods. The comparison with veterans who contacted the line in earlier years was not randomized, so differences between the groups other than the letters cannot be excluded. The study population was overwhelmingly male and drawn from one health system, and the journal’s summary page does not report hazard ratios or confidence intervals for the mortality comparisons. The full report may contain detail not available on the abstract page.
Veterans in crisis can reach the Veterans Crisis Line by dialing 988 and pressing 1, by texting 838255, or by online chat, 24 hours a day, according to the UW release. Anyone in the United States can call, text or chat with the 988 Suicide and Crisis Lifeline, which is free and confidential, Washington State’s Department of Health notes.
This article is for general information and does not replace advice from a qualified clinician. Corrections: email the editor using the address on the Contact page.
