Treating PTSD Among Veterans at Risk for Suicide

Veterans face higher rates of trauma exposure than nonveterans, with such exposures spanning pre–military service, military service, and post separation.¹ A portion of individuals exposed to traumatic events will develop posttraumatic stress disorder (PTSD), which is an identified risk factor for suicidal thoughts and behaviors.^2,3 Effectively treating PTSD and its associated consequences requires that veterans have access to optimally delivered, evidence-based care.

Treatment Options

The current Department of Veterans Affairs (VA) and Department of Defense clinical practice guideline (CPG) identifies trauma-focused psychotherapies (eg, cognitive processing therapy [CPT], prolonged exposure therapy [PE]) as the recommended intervention for PTSD, with strong evidence of their potential to reduce PTSD symptoms.⁴ There are several additional psychotherapy (eg, present-centered therapy) and medication (eg, sertraline) treatments that are suggested for PTSD.⁴ Some research suggests that, in addition to reducing PTSD symptoms, evidence-based treatments for PTSD also may reduce suicide risk. For example, a systematic review of interventions for co-occurring suicidal thoughts and behaviors and PTSD highlighted that several interventions—particularly those directly targeting PTSD or both PTSD and suicide risk—appear to attenuate risk for suicidal thoughts and behavior.⁵ Moreover, several medications used to treat PTSD (eg, sertraline) have demonstrated potential to reduce suicide risk, even when provided within the context of complex psychiatric comorbidities (eg, depression).⁶

Shared Decision-Making

Given the variety of treatment options that can be provided to veterans with PTSD, clinicians should utilize shared decision-making as a patient-centered approach to treatment planning.⁷ In shared decision-making, the clinician works collaboratively with the veteran to identify and consider available evidence-based treatments, discuss factors that may facilitate (eg, openness to trauma-focused treatment) or impede (eg, transportation difficulties or job-related time commitments) the treatment process, and ultimately select the treatment that is the best fit for the veteran at that time. Throughout the shared decision-making process, clinicians can collaborate with the veteran to problem-solve barriers to treatment engagement and success. For example, they may coordinate with case managers to navigate contextual barriers (eg, bus pass for transportation difficulties, working with the veteran and their employer to facilitate time off for PTSD treatment). Similarly, clinicians can discuss treatments that are briefer in nature (eg, written exposure therapy) or massed in their approach (ie, more frequent, intensive administrations of psychotherapy), which have the potential to yield more rapid treatment response (thereby mitigating potential scheduling burdens).^4,8

Tailoring Care to Address Suicide Risk

Even when a PTSD treatment approach is collaboratively selected, providing care in the context of concurrent suicide risk can be inherently complex. Many clinicians are hesitant to provide such care due to fears of exacerbating suicide risk.⁹ To navigate this complexity, clinicians should carefully assess the patient’s suicide risk, utilizing a therapeutic risk management approach wherein standardized and validated approaches (eg, the Columbia-Suicide Severity Rating Scale) are used to assess factors relevant to suicide risk, including recent suicidal thoughts and behaviors, as well as risk and resilience factors. These data can be used to inform acute (ie, near future) and chronic (ie, longer-term) risk for suicide.¹⁰

For veterans with PTSD and low or intermediate acute risk for suicide, PTSD treatment can be provided alongside appropriate suicide risk management.^11,12 In navigating care for these veterans, clinicians can consider several risk management strategies, such as developing a safety plan and updating it throughout the course of treatment, as well as ongoing monitoring to detect meaningful fluctuations in acute risk (eg, development of suicidal intent, engaging in suicidal behavior).¹³ Moreover, clinicians can consider augmenting PTSD treatment with strategies that target suicide risk factors, such as cognitive restructuring surrounding hopelessness or perceived burdensomeness.¹⁴

For some veterans, however, it may not be appropriate to engage in trauma-focused treatment initially.¹⁵ For example, individuals who engage in unhealthy behaviors when encountering reminders of their trauma (eg, nonsuicidal self-directed violence [often called nonsuicidal self-injury] such as cutting, head banging, or wall-punching) or with a recent suicide attempt, may benefit from initially focusing upon foundational coping skills before initiating trauma-focused treatment. In these instances, veterans may benefit from a phase-based approach wherein the veteran first focuses on the development of effective coping strategies and reduction of unhealthy behaviors before proceeding to trauma-focused treatment. For example, dialectical behavior therapy (DBT) and psychoeducation provide an initial course of DBT (a structured behavioral intervention to reduce suicide risk by improving emotion regulation), followed by a trauma-focused psychotherapy.¹⁶ In utilizing a phase-based approach, clinicians can work with the veteran to develop adequate scaffolding to approach processing the trauma, while remaining goal oriented on ultimately treating the underlying PTSD. When using this phase-based approach to care, it is important for clinicians and veterans to keep in mind the goal of transitioning into trauma-focused psychotherapy, as PTSD symptoms are most likely to reduce during the trauma-focused phase of care.¹⁷ Without an intentional approach to phase-based care, clinicians and veterans may have difficulty making the transition.^18,19

In rare circumstances, hospitalization may be warranted for veterans at high acute risk for suicide whose acute risk cannot be safely managed in an outpatient setting. Following discharge from hospitalization, clinicians may reconsider factors necessary to enable trauma-focused treatment, including additional coping skills when clinically indicated, as well as treatments focused on preventing suicide directly (eg, DBT).

Concluding Thoughts

In sum, PTSD significantly impacts the veteran population. Evidence-based treatment options, including efficacious trauma-focused treatments, are available for PTSD. Providers can provide these interventions to veterans with PTSD, even in the presence of concurrent suicide risk. When navigating care, providers should consider collaborative, shared decision-making to select a treatment approach that best meets the veteran’s needs. Should enhanced scaffolding be warranted, providers can consider phase-based approaches to provide the veteran with necessary skills to mitigate risk while remaining ultimately focused on treating the PTSD.

Dr Holliday is a clinical research psychologist at the VA Pacific Islands Health Care System and the VA Eastern Colorado Health Care System, and an assistant professor at the University of Colorado Anschutz Medical Campus. Dr Edwards is a clinical research psychologist at the VISN 2 Mental Illness Research, Education, and Clinical Center and an assistant professor at the Icahn School of Medicine at Mount Sinai. Dr Holder is a clinical research psychologist at the San Francisco VA Health Care System and the Center for Data to Discovery and Delivery Innovation, and an assistant professor at the University of California, San Francisco School of Medicine. Dr Monteith is a clinical research psychologist in the VA Pacific Islands Health Care System and an associate professor at the University of Colorado Anschutz Medical Campus.

References

1. Lehavot K, Katon JG, Chen JA, et al. Post-traumatic stress disorder by gender and veteran status. Am J Prev Med. 2018;54(1):e1-e9.

2. Holliday R, Borges LM, Stearns-Yoder KA, et al. Posttraumatic stress disorder, suicidal ideation, and suicidal self-directed violence among U.S. military personnel and veterans: a systematic review of the literature from 2010 to 2018. Front Psychol. 2020;11:1998.

3. Pompili M, Sher L, Serafini G, et al. Posttraumatic stress disorder and suicide risk among veterans: a literature review. J Nerv Ment Dis. 2013;201(9):802-812.

4. Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 2023. Accessed August 17, 2026. https://www.healthquality.va.gov/HEALTHQUALITY/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPG-Edited-111624-V5-81825.pdf

5. Rozek DC, Baker SN, Rugo KF, et al. Addressing co-occurring suicidal thoughts and behaviors and posttraumatic stress disorder in evidence-based psychotherapies for adults: a systematic review. J Trauma Stress. 2022;35(2):729-745.

6. Sher L, Stanley BH, Posner K, et al. Decreased suicidal ideation in depressed patients with or without comorbid posttraumatic stress disorder treated with selective serotonin reuptake inhibitors: an open study. Psychiatry Res. 2012;196(2-3):261-266.

7. Larsen SE, Hooyer K, Kehle-Forbes SM, et al. Patient experiences in making PTSD treatment decisions. Psychol Serv. 2024;21(3):529-537.

8. Wachen JS, Dondanville KA, Evans WR, et al. Adjusting the timeframe of evidence-based therapies for PTSD-massed treatments. Curr Treat Options Psychiatry. 2019;6(2):107-118.

9. LoSavio SV, Holder N, Wells SY, Resick PA. Clinician concerns about cognitive processing therapy: a review of the evidence. Cogn Behav Pract. 2024;31(2):152-175.

10. Wortzel HS, Homaifar B, Matarazzo B, et al. Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014;20(1):63-67.

11. Bryan CJ. Treating PTSD within the context of heightened suicide risk. Curr Psychiatry Rep. 2016;18(8):73.

12. Holliday R, Holder N, Williams AM, Monteith LM. Treating PTSD in the context of concurrent suicide risk: current evidence and navigating complicating factors. Curr Treat Options Psych. 2021;8:213-228.

13. Holliday R, Rozek DC, Smith NB, et al. Safety planning to prevent suicidal self-directed violence among veterans with posttraumatic stress disorder: clinical considerations. Prof Psychol Res Pr. 2019;50(4):215-227.

14. Holder N, Holliday R. Delivering cognitive processing therapy in the context of suicide risk, violence risk, and intense psychosocial stressors. In: Wachen JS, Galovski TE, eds. Cognitive Processing Therapy for Complex Cases. CBT: Science Into Practice. Springer; 2025:229-254.

15. Goodnight JRM, Ragsdale KA, Rauch SAM, et al. Psychotherapy for PTSD: an evidence-based guide to a theranostic approach to treatment. Prog Neuropsychopharmacol Biol Psychiatry. 2019;88:418-426.

16. Harned MS. Treating Trauma in Dialectical Behavior Therapy: The DBT Prolonged Exposure Protocol (DBT PE). Guilford Press; 2022.

17. Harned MS, Gallop RJ, Valenstein-Mah HR. What changes when? The course of improvement during a stage-based treatment for suicidal and self-injuring women with borderline personality disorder and PTSD. Psychother Res. 2018;28(5):761-775.

18. Holder N, Ranney RM, Delgado AK, et al. Transitioning into trauma-focused evidence-based psychotherapy for posttraumatic stress disorder from other treatments: a qualitative investigation. Cogn Behav Ther. 2025;54(3):391-407.

19. Holder N, Ranney RM, Delgado AK, et al. Transitioning into trauma-focused evidence-based psychotherapy for posttraumatic stress disorder from other treatments: a qualitative investigation of clinicians’ perspectives. Cogn Behav Ther. 2026;55(2):185-203.