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Many providers experience reluctance to directly address trauma-related symptoms and disorders out of fear that they may push the client too far and trigger strong emotional reactions and/or behavioral dysregulation. This fear can be exacerbated for the significant portion of clients with posttraumatic stress disorder (PTSD) who also experience suicidal thoughts (SI) and behaviors. Over the last decade suicide rates have increased in the U.S., particularly amongst active duty military personnel and veterans (American Foundation for Suicide Prevention, 2020; Department of Veterans Affairs [VA], 2019). Even more concerning is that PTSD is one of few psychological risk factors associated with increased risk for suicidal behaviors and death (Legarreta et al., 2015; Pompili et al., 2013). However, patient and provider fear of triggering a suicidal episode can delay effective treatment of PTSD symptoms (i.e., individual trauma-focused interventions with cognitive restructuring and exposure elements; Bryan, 2016; Harned et al., 2010; Stirman, 2008; VA/DoD, 2019). Without targeted PTSD treatment, PTSD symptoms and related problems are unlikely to remit, prolonging suffering and risk for suicide. 

Fortunately, as a wealth of data on evidence-based therapies for PTSD has become available, so have insights into their tolerability and safety, even for high-risk individuals. For example, cognitive processing therapy (CPT), one of the evidence-based treatments for PTSD with the highest clinical practice recommendation (VA/DoD, 2019), can be safely and effectively delivered to individuals with increased risk for suicide (Holliday et al., 2018; Stayton et al., 2019) and may even help to reduce SI (Resick et al., 2017). However, existing inquiries have been limited to those at relatively low risk for suicide. Thus, clinicians working with individuals at high risk for suicide are unsure of how to treat their patients’ PTSD while managing their suicide risk. 

In order to answer this critical clinical question, we explored and compared the safety (i.e., absence of suicidal behavior), tolerability (i.e., ability to complete treatment), and effectiveness (i.e., symptom reduction) for veterans participating in CPT with varying levels of suicide risk in a VA outpatient PTSD clinic. Retrospective chart reviews that spanned a four-year period documented presence of SI and suicidal behaviors prior to and after engaging in CPT, as well as treatment attendance and response. Suicide data from chart review was used to assign veterans a suicide risk level. Of the 290 veterans whom participated in CPT in this time period, 46% (n = 134) were categorized as low risk (denied current SI or history of suicide attempt), 43.4% (n = 126) were at elevated risk (current SI OR history of suicide attempt), and 10% (n = 29) were identified as high risk (current SI and history of suicide attempt). 


  • Three veterans (1.0%) engaged in suicidal behavior between treatment initiation and chart review. 
  • Per records, no veteran who engaged in CPT in this clinic since 2016 has died by suicide.
  • High risk veterans were just as likely to complete treatment as low risk veterans.
  • Suicide risk groups experienced similar levels and rate of PTSD symptom change over the course of treatment. 
  • On average, veterans reported clinically significant reduction of PTSD symptoms.

Figure 1Figure 1. Posttraumatic Stress Disorder Symptom Severity Change Trajectories, by Suicide Risk Group, for Cognitive Processing Therapy Completers

 A secondary aim of this investigation was to provide clinically useful, empirically based rankings of suicide risk. After over 50 years of suicide research, nearly 3,500 risk factors for suicide have been identified, however, they have not improved our ability to predict suicidal behaviors and death (Franklin et al., 2017). We utilized two suicide risk categorization approaches and compared their predictive utility. Similar to previous findings, history of suicide attempts did predict variability in outcomes, however, suicidal thoughts did not. 

This was amongst the first investigations of treating PTSD with CPT in a high-risk population. Results indicate that individuals with co-morbid PTSD and suicide risk can safely participate in CPT with good benefit. Providers and patients alike can be reassured that we have a treatment for PTSD that can alleviate suffering, even for those with more complicated presenting concerns. 

Reference/Target Article

Roberge, E.M., Harris, J.A., Weinstein, H.R., & Rozek, D.C. (2021). Treating veterans at risk for suicide: An examination of the safety, tolerability, and outcomes of cognitive processing therapy. Journal of Traumatic Stress.

Discussion Questions

  • What concerns do you have about treating high risk patients with PTSD?
  • In what cases might directly addressing thoughts and behaviors that maintain suicide risk be more effective than targeting PTSD symptoms specifically?
  • How can evidence based treatments for PTSD be integrated with empirically based suicide management strategies to best support high risk patients with PTSD?

About the Authors

Erika M. Roberge, PhD
 is a clinical investigator and staff psychologist on the PTSD and Dialectical Behavior Therapy Teams at the Salt Lake City VAMC. She is the principal investigator of the SLC VAMC’s PTSD Research Clinic where she studies patient and treatment variables that influence effectiveness of cognitive processing therapy for PTSD, as well as the relationships between trauma, suicide risk, and insomnia in the onset and maintenance of each of these presenting concerns. She is also a trainer of Crisis Response Planning for the state of Utah. She can be contacted at Erika.Roberge@va.gov .
Julia A. Harris, M.S. is a predoctoral intern at the SLC VAMC with an emphasis on clinical training in general outpatient mental health and Dialectical Behavioral Therapy. She has extensive clinical and research training in the assessment and treatment of post-traumatic stress disorder, as well as suicidal thoughts and behaviors. Julia Harris can be contacted at Julia.harris1@va.gov
Harrison Weinstein, PhD, is a clinical psychologist at the Salt Lake City VA Medical Center where he works on the PTSD Clinical and Polytrauma Teams. He is a VISN 19 regional Cognitive Processing Therapy trainer and consultant, and also serves as the associate director of psychology training. Dr. Weinstein’s research interests focus on treatment consistent modifications of Evidence Based Psychotherapies for PTSD. He can be contacted at Harrison.Weinstein@va.gov.

David Rozek, PhD, ABPP, 
is an assistant professor at UCF RESTORES and the Department of Psychology at the University of Central Florida. Dr. Rozek’s research and clinical expertise are in cognitive and behavioral therapies for suicide, depression, and PTSD. He regularly provides training to clinicians and medical professionals about managing suicidal patients and is an active researcher focusing on how to best improve clinical care. Dr. Rozek can be contacted at david.rozek@ucf.edu and he can be found on Twitter @davidrozekphd. 

References Cited

American Foundation for Suicide Prevention. (2020). Suicide statistics. Retrieved from https://afsp.org/suicide-statistics

Department of Veterans Affairs. (2019). 2019 National veteran suicide prevention annual            report. Retrieved from https://www.mentalhealth.va.gov/docs/data-         sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf
Department of Veterans Affairs, Department of Defense (2019). VA/DoD clinical practice            guideline for the assessment and management of patients at risk for suicide. Version            2.0. https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Musacchino, K. M., Jaroszewski, A.C., Chang, B. P., & Nock, M .K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187-232. https://doi.org/10.1037/bul0000084
Harned, M. S., Jackson, S. C., Comtois, K. A., & Linehan, M. M. (2010). Dialectical behavior therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with borderline personality disorder. Journal of Traumatic Stress23(4), 421–429. https://doi.org/10.1002/jts.20553
Holliday, R., Holder, N., Monteith, L. L., & Surís, A. (2018). Decreases in suicide cognitions after cognitive processing therapy among veterans with posttraumatic stress disorder due to military sexual trauma: A preliminary examination. Journal of Nervous and Mental Disease206(7), 575–578. https://doi.org/10.1097/NMD.0000000000000840
Legarreta, M., Graham, J., North, L., Bueler, C. E., McGlade, E., & Yurgelun-Todd, D. (2015). DSM–5posttraumatic stress disorder symptoms associated with suicide behaviors in veterans. Psychological Trauma: Theory, Research, Practice, and Policy7, 277–285. https://doi.org/10.1037/tra0000026
Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., Lester, D., Amore, M., & Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. Journal of Nervous and Mental Disease201(9), 802–812. https://doi.org/10.1097/NMD.0b013e3182a21458
Resick, P. A., Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Yarvis, J. S., Peterson, A. L., & Mintz, J. (2017). Effect of group vs. individual cognitive processing therapy in active-duty military seeking treatment for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry74(1), 28–36. https://doi.org/10.1001/jamapsychiatry.2016.2729
Stirman, S. W. (2008). The applicability of randomized controlled trials of psychosocial treatments for PTSD to a veteran population. Journal of Psychiatric Practice14(4), 199–208. https://doi.org/10.1097/01.pra.0000327309.58411.e0