Group-Based Suicide Safety Planning and Skills Training for Veterans With High Suicide Risk: A Randomized Clinical Trial.

Importance: Novel evidence-based suicide-specific treatments are critical to addressing rising rates of suicide among veterans. Objective: To determine whether Project Life Force (PLF), a group intervention that augments suicide safety planning (SSP) with skills training, plus treatment as usual (TAU) delays or decreases suicidal behavior compared with TAU alone. Design, Setting, and Participants: This multisite randomized clinical trial, using intention-to-treat analyses, included veterans at high risk for suicide. Participants were recruited after psychiatric inpatient discharge or referral from 4 Veterans Health Administration outpatient care teams in hospitals in Pennsylvania, New York, and Texas between March 2018 and February 2024. Data were analyzed from April 2024 to October 2025. Intervention: PLF is a manualized, 10- to 12-session (75-90 minutes per session) group intervention combining SSP with distress tolerance, emotion regulation, and interpersonal skills training. Sessions cover each of the 6 SSP steps, health management, reasons for living, SSP accessibility, and a recap, with up to 4 optional booster sessions offered. All participants received TAU, constituting individual SSP and standard outpatient mental health care. Main Outcomes and Measures: The primary outcome was time in days to first suicidal behavior (aborted, interrupted, or actual attempts or suicide death) over 12 months, assessed using the Columbia Suicide Severity Rating Scale and chart review. Secondary outcomes over 12 months included self-report measures of hopelessness, depression, treatment use, attitudes toward help-seeking, and suicide-related coping. Results: A total of 207 participants (mean [SD] age, 46.1 [13.9] years; 178 male [86%]) were assessed at baseline and randomly assigned to PLF plus TAU (101 participants) or TAU alone (106 participants). Cox proportional hazards models showed no significant between-group difference in time to suicidal behavior; however, compared with TAU, PLF participants had a lower hazard of actual suicide attempts over 1 year (HR, 0.49; 95% CI, 0.26-0.92; P = .03). Secondary outcome analyses included data from 132 participants (64%) at posttreatment, 125 (60%) at month 6, and 130 (62%) at month 12. Treatment-by-time effects ranged from Cohen d = -0.03 to 0.35. Notably, PLF significantly improved suicide-related coping at posttreatment (estimate, 4.06; Cohen d, 0.21; P = .04) and month 6 (estimate, 5.36; Cohen d, 0.27; P = .007). No study-related adverse events occurred. Conclusions and Relevance: In this randomized clinical trial of 207 participants, PLF plus TAU did not change time to suicidal behavior but did increase time to actual suicide attempts and improve suicide-related coping, thereby enhancing SSP impact. Trial Registration: ClinicalTrials.gov Identifier: NCT03653637.