title: Trust is the basis for effective suicide risk screening and assessment in veterans.
abstract: BACKGROUND
  To reduce suicides among Veterans, the Department of Veterans Affairs (VA) has designated suicide risk assessments for Veterans who screen positive for depression or post-traumatic stress disorder as a national performance goal. Many VA Medical Centers (VAMCs) are using brief suicidal ideation screens, administered in non-mental health ambulatory care settings, as the first step in the assessment process.
  
  
  OBJECTIVE
  To explore Veterans' perceptions of the suicide screening and risk assessment process, the barriers and facilitators to disclosing suicidal thoughts, and perceptions of possible consequences of revealing suicidal thoughts.
  
  
  METHODS
  Investigators recorded one semi-structured interview with each Veteran. Transcripts were analyzed using a modified grounded theory approach.
  
  
  METHODS
  Thirty-four Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans who screened positive for suicidal ideation in non-mental health ambulatory care settings in 2009 and 2010.
  
  
  RESULTS
  Veterans accepted the need to assess suicide risk. They increasingly experienced attempts to suppress and avoid thoughts of suicide as burdensome and exhausting. Despite this, Veterans often failed to disclose severe and pervasive suicidal thoughts when screened because: (1) they considered suicidal thoughts as shameful and a sign of weakness; (2) they believed suicidal thoughts were private and not to be divulged to strangers; (3) they worried that disclosure would lead to unwanted hospitalization or medication recommendations; and (4) the templated computer reminder process was perceived as perfunctory and disrespectful. In contrast, admitting and discussing thoughts of suicide with a health provider who focused on building a relationship, demonstrated genuineness and empathy, offered information on the rationale for suicide risk assessment, and used straightforward and understandable language, all promoted trust that resulted in more honest disclosure of suicidal thoughts.
  
  
  CONCLUSIONS
  In ambulatory care settings, both provider behaviors and system modifications may lead to more honest disclosure of suicidal thoughts.
authors.affiliation: Portland Center for the Study of Chronic, Comorbid Physical and Mental Disorders, Portland Veterans Affairs Medical Center, Portland VA Medical Center, Portland, OR 97207, USA. linda.ganzini@va.gov
authors.forename: Linda
authors.initials: L
authors.lastname: Ganzini
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Denneson
authors.forename: Nancy
authors.initials: N
authors.lastname: Press
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bair
authors.forename: Drew A
authors.initials: DA
authors.lastname: Helmer
authors.forename: Jennifer
authors.initials: J
authors.lastname: Poat
authors.forename: Steven K
authors.initials: SK
authors.lastname: Dobscha
mesh_terms: D000328:Adult; D001294:Attitude to Health; D003863:Depression / Q000523:psychology; D005260:Female; D006801:Humans; D007406:Interview, Psychological; D008297:Male; D008403:Mass Screening / Q000379:methods / Q000523:psychology; D010342:Patient Acceptance of Health Care / Q000523:psychology; D011369:Professional-Patient Relations; D018570:Risk Assessment / Q000379:methods; D013313:Stress Disorders, Post-Traumatic / Q000523:psychology; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology; D035502:Trust; D014342:Truth Disclosure; D014481:United States; D014728:Veterans / Q000523:psychology*; D000092864:Suicide Prevention