By Tiffany Milligan, PsyD, MBA & Marija Kelber, Ph.D. 
July 17, 2024

U.S. Army Reserve photo by Staff Sgt. Christopher Hernandez

Each year, governments and communities around the world invest significant resources into prevention of suicide. The lack of effective interventions, however, makes suicide prevention challenging.¹ The Department of Defense continually evaluates promising suicide prevention approaches to integrate into the Military Health System. Recently, our Evidence Synthesis & Dissemination team at Psychological Health Center of Excellence conducted a rapid review of case management interventions for suicide prevention. Case managers play an important role in the care of military service members and veterans, many of whom have complex healthcare needs.² The goal of our rapid review was to evaluate the applicability of case management programs for suicide prevention in the DOD.

In general, case managers support the provider’s treatment plan for a patient, though their specific duties may vary widely. ³ Since the licensed provider is the person who must make care decisions, individuals like case managers are often the ones who provide education to and gather information from patients.⁴  Many different types of professionals may fulfill the role of case manager. In the United States, this is often done by social workers, nurses, and other individuals with bachelor’s degrees. The DOD and the Department of Veterans Affairs launched a program designed for service members and veterans with polytrauma employed using registered nurses and social workers to serve as case managers.²

Within the field of mental health, suicide prevention is high priority. Among the general population of the United States, it’s the second leading cause of death for Americans between the ages of 10 and 64.⁶ Rates are similar for the active duty military population.⁷ For service members, behavioral health diagnoses, relationship problems, issues in the workplace, and legal/financial problems have been linked to an increased risk of suicide. For some of these “problems of living” (i.e., relationships, work, money), services apart from a medical provider’s intervention may be needed. For instance, community programs that assist with a service member’s financial problems, or groups and services within the healthcare system that specifically address relationship concerns, may be helpful. The Military and Family Life Counseling Program is an example of such a service. MFLC is available on military bases to offer individuals non-medical guidance and counseling for relationship and readiness issues.⁸ Connecting patients with these types of resources is often one role of case managers.⁵

For suicide prevention, there are many other tasks a case manager may perform beyond resource connection. The specifics of these tasks are at least partially dictated by the level of need of the patient population. For instance, for patients with severe mental illness, intensive case management is a model that is often employed.⁹ ICM emphasizes smaller caseloads, long-term follow-up, and frequent contact with patients. In general, the goals of ICM are to reduce hospital admissions and keep patients engaged with services so they may remain in the community for as long as possible. These models tend to yield positive results on suicide-related measures, reducing attempts and utilization of crisis services. Three studies with the VA’s Mental Health Intensive Case Management program showed reductions in suicide behaviors,¹⁰ suicide attempts,¹¹ and hospital admissions.¹² In the DOD, ICM has not historically been used as part of a suicide prevention program, though extended connection with case management has become more common as service members have returned from Operation Enduring Freedom and Operation Iraqi Freedom.² The Wounded Warrior Program is one MHICM program example that supports soldiers returning from the OEF/OIF conflicts with severe injuries or illnesses.¹³ Advocates who guide service members through all phases of this program are often case managers. They are the critical link between the service member and the wide range of services afforded to them by the program. Another patient population often benefiting from case management services are individuals diagnosed with borderline personality disorder. In Linehan’s dialectical behavioral therapy, a case management skills group is built into treatment for patients with BPD. One study by Linehan found that the case management skills group helped reduce the frequency of non-suicidal self-injury,¹⁴ a common concern with BPD. When compared to a psychotherapy, an enhanced therapeutic case management intervention performed equally well.¹⁵ It is unclear how applicable these results are for Service members who are typically not impacted by SMI or BPD, but these results are encouraging regarding case management’s effectiveness for suicide prevention with individuals with complex health care needs.

Finally, another area of suicide prevention in which case managers have figured prominently is multilevel suicide prevention programs. In these types of programs, clinicians, hospitals, and governmental leaders work together to reduce suicide rates in areas with higher risk. A study in Japan that covered 11 geographical regions utilized case managers to assist with a program that included a public education campaign, depression screening, phone assessment and feedback, and treatment. This study found a reduction in suicide deaths.¹⁶

Although case management programs are utilized in the Military Health System, our rapid review did not yield examples of case management programs for suicide prevention in the military that met all literature search criteria. These studies in other settings and populations may be informative for developing such programs. Longer term engagement with case management has proven effective with veterans at risk of suicide, and it has proven helpful with service members for improving health and well-being after deployment. The multilevel interventions with geographic populations may be applicable to the military given its unique culture. Suicide prevention programs that intervene with not only the service member, but also multiple levels of leadership and the military installation might be impactful. Care teams in general, and case managers in particular, provide essential support that makes programmatic suicide prevention efforts possible. The studies highlighted here showed promising results, but it’s important to note that other studies had mixed or inconclusive findings. More research on these programs in general, and with military populations in particular, is needed to advance our goal of suicide prevention.

References

1. Fox, K. R., Huang, X., Guzmán, E. M., Funsch, K. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research. Psychological Bulletin, 146(12), 1117–1145. https://doi.org/10.1037/bul0000305
2. Perla, L. Y., Jackson, P. D., Hopkins, S. L., Daggett, M. C. & Van Horn, L. J. (2013). Transitioning Home: Comprehensive case management for America’s heroes. Rehabilitation Nursing Journal, 38(5), 231-239. 
3. Chen, W. J., Chen, C. C., Ho, C. K., Lee, M. B., Lin, G. G., & Chou, F. H. (2012). Community-based case management for the prevention of suicide reattempts in Kaohsiung, Taiwan. Community Mental Health Journal, 48(6), 786-791. doi: 10.1007/s10597-012-9480-7.
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5. American Case Management Association. 2023. Case Management: Standards of Practice & Scope of Services. https://www.acmaweb.org/forms/Standards_of%20Practice_Scope_of%20Services_Brochure.pdf.
6. Centers for Disease Control and Prevention (CDC). (2023, May 8). Facts about Suicide. https://www.cdc.gov/suicide/facts/index.html
7. Department of Defense. (2022). Annual report on suicide in the military: Calendar year 2021. Under Secretary of Defense for Personnel and Readiness. https://www.dspo.mil/Portals/113/Documents/2021%20ASR/Annual%20Report%20on%20Suicide%20in%20the%20Military%20CY%202021%20with%20CY21%20DoDSER.pdf
8. Military One Source. (n.d.). Military and family life counseling. https://www.militaryonesource.mil/benefits/military-family-life-counseling-program/
9. Fernández-Miranda, J. J., Díaz-Fernández, S., & López-Muñoz, F. (2022). Effectiveness of More Personalized, Case-Managed, and Multicomponent Treatment for Patients with Severe Schizophrenia Compared to the Standard Treatment: A Ten-Year Follow-Up. Journal of Personalized Medicine, 12(7). https://doi.org/10.3390/jpm12071101
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11. Mohamed, S. (2022). Rates and Correlates of Suicidality in VA Intensive Case Management Programs. Community Mental Health Journal, 58(2), 356-365. https://doi.org/10.1007/s10597-021-00831-8
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13. Kelley, P. W., Kenny, D. J., Gordon, D. R., Benner, P. (2015). The evolution of case management for service members injured in Iraq and Afghanistan. Qualitative Health Research, 25(3):426-439. https: //doi.org/10.1177/1049732314553228
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Dr. Tiffany Milligan is a clinical health psychologist with extensive experience in primary care behavioral health and with clinician training. She joined the PHCoE Research Execution team as a contractor in 2022 as a clinical subject matter expert.

Dr. Marija Kelber is a research psychologist and a team lead for Evidence Synthesis and Dissemination at the PHCoE.